MEDICINE,
SCIENCE AND SOCIETY
Public Health in China: 1978 MICHAEL
H. ALDERMAN,
M.D
R society
apid change is characteristic of all aspects of Chinese today. It was against this background that we, as members of two medical groups, viewed China during 18 days in April and 15 in October 1978. In sum, we traveled more than 2,000 miles within China, viewed health facilities in seven cities and three communes. We visited hospitals, clinics, medical schools and the National Cardiovascular Research Center at Fu Wei Hospital in Peking. We met with probably 200 health workers, including physicians, nurses, barefoot doctors, worker doctors, health educators and administrators, and spoke, usually through interpreters, with perhaps 100. Despite the possibility that in such a huge country the distillation of our combined observations may bear little more resemblance to reality than the proverbial description of the elephant by the six blind men, we feel compelled to share our impressions of public health and medicine in China today. Like most other travellers, we were captivated by the warmth and openness of our Chinese collctagues and the esprit of the Chinese people everywhere.
ancl GEORGE
G. READER,
M.D.
does contribute to the apparently high prevalence of respiratory tract infection. There appears to be enough food for everyone, although staples including rice, meat and cooking oil are rationed to ensure their equitable distribution. An average family has meat two or three times a week at most. In northern China, noodles instead of rice are the staple, but wheat bread is being introduced. There does not appear to be serious malnutrition anywhere. Human waste is collected daily and used as night soil to manure the fields. Although it is supposed to be composted for at least two weeks heforc being applied, this practice is not always carefully followed in rural areas of the South. Garbage is also composted and applied to the fields. In some areas, solid waste is buried or burned. Air pollution seems to be a growing problem in industrial areas such as Shanghai and may contribute to the prevalence of cancer of the respiratory tract. Smoking is widespread, especially among men.
CHILD
HYGIENE Living conditions, as they relate to health, encompass water supply, clothing, housing, food and waste disposal. Although little potable water is available, the ubiquitous thermos bottle with hot water for tea, as well as the plentiful supply of beer and orange soda, appear sufficient to prevent waterborne disease. Except in the far north, and in some hotels and hospitals of western design, there is no central heating. As winter approaches, down-padded clothing becomes the main protection against cold and is often not taken off until spring. Bathing is accomplished in tubs, usually wooden, in mch household, or in some communes and housing projects, in winter, central bath facilities arc available. Housing is in short supply, but Chinese families have traditionally lived in what we might consider crowded conditions. Exposure to cold and crowding probably
CARE
Children receive exemplary attention. Trained midwives do the majority of deliveries in rural China. In the cities, deliveries are commonly done in the hospital where the mother is routinely sterilized after the second child. Immunizations are provided for the common childhood diseases except measles, and BCG vaccine isgiven to every child. After BCG vaccination, children are followed up by chest X-Ray at regular intervals. No child goes longer than 46 months without an examination. Rheumatic fever is said to have been controlled, but upper respiratory tract infections are common; there appear to be no facilities for culture of microorganisms outside of central hospitals. Otoscopes seem to be nonexistent. Head mirrors are in use in hospitals but not in clinics. Prevalence of middle ear infection is probably high since there is considerable mastoiditis. Rheumatic valvular disease is c:ommon. hut rheumatic fever is now believed to be imder control.
July 1979 The American
Journal
of Medicine
Volume
67
3
MEDICINE,
SCIENCE
TABLE I
AND
SOCIETY-ALDERMAN,
MORTALITY-United Shanghai 1972
Cause Cardiovascular (% ) Stroke lschemic heart disease Cancer (%)
States and China Peking 1977
31
United Stales 1975 52
53 24
19 -
READER
a
25
10 37
23
19.3
MEDICATIONS A wide range of modern drugs are available in hospitals, but in the barefoot doctor’s clinic in one commune only sulfathiazole and chloramphenicol were present besides a large number of Chinese medicines. The traditional medicines are said to be highly effective but are used empirically without any knowledge of dose/response relationships or basic mechanisms of action, although studies have begun in some centers on the pharmacology of these drugs. In addition to drugs prescribed in hospitals, patients may purchase a large number of traditional and western drugs, ranging from ginseng to colistin to cantharides, over the counter. ACUPUNCTURE
ANESTHESIA
Acupuncture has been used since about 1958 as a regular anesthetic for major surgery. It appears to be most popular in Shanghai, where surgeons claim it can be used in 98 per cent of operations. In Peking it is considered particularly useful for superficial (i.e., head, neck and thoracic) surgery and for some gynecologic procedures, but Peking surgeons believe it does not provide adequate relaxation for most abdominal surgery. Four operations were observed in Shanghai in the Cardiopulmonary Hospital, all using acupuncture. The patients were women in their 3Os, one with an adenocarcinoma of the right middle lobe, one with a patent ductus and two with mitral stenosis. Ten milligrams of morphine were given as premeditation. An acupuncture needle was inserted into the right forearm and 4 V of pulsating direct current applied. Induction required about 15 minutes. The patients remained awake throughout. Only the patient undergoing lobectomy required intubation. Oxygen was given intermittently. The patients appeared to feel no discomfort, sipped water and spoke with the acupuncturist. A main function of the acupuncturist during the operation was to provide a breathing rhythm for the patient. We were told that patients are admitted a week before operation to learn diaphragmatic breathing, much as is done in natural childbirth. The surgeons were deft and quick. With electrocautery there was little bleeding, and all the operations were completed in a little over z hours. A PUBLIC
HEALTH
CAMPAIGN
During our stay in China, the annual National Patriotic Public Hygiene Campaign was in progress. In Peking
4
July 1979
The American Journal of Medicine
Volume 67
we passed sound trucks exhorting the public to eliminate the traditional four pests (flies, rats, mosquitos and bed bugs), eschew public spitting, air their bedding and brush their teeth regularly. An enormous Sunday Parade had been held to publicize the theme of domestic hygiene. In Shanghai, retired workers waving banners lined the main commercial thoroughfares while bands played and huge posters announced the presence of health workers presenting displays where microbes could be viewed through microscopes. Unable to speak the language, we could not accurately judge public response, yet it was clear that very large numbers of people were directly involved in the campaign. It is true that flies are now rare in China; birds also have been virtually eliminated. A CARDIOVASCULAR
CENTER
In contrast to reports provided by Dr. Side1 in 1972, cardiovascular disease was found to have replaced cancer as the leading cause of death in Peking (Table I] [l]. The distribution of cardiovascular deaths was, however, considerably different in China compared with that in the United States. Strokes accounted for some 45 per cent of the total, and myocardial infarctions for less than 15 per cent. During a visit to the Fu Wei Hospital, Drs. Tao Sho-Chi and Lui Li Shang described results of their long-term observations of more than 100,000 persons who comprised the population of an urban industrial mill and a rural commune. In view of the increasing incidence of cardiovascular morbidity, and the known association of high blood pressure with stroke and heart disease, these investigators had begun studies of hypertension within their two communities. The prevalence of this condition was found to be about 7 per cent in the rural and 9 per cent in the urban group. These figures are based upon hypertension being defined as a 4th Korotkoff sound above 90 mm Hg. This technique is a more sensitive definition of hypertension than is the American practice and, therefore, suggests that despite the high incidence of stroke, hypertension is less common in China than here. A prospective study of antihypertensive therapeutic intervention for urban residents with diastolic pressures less than 100 mm Hg was begun in 1973. Western drugs-diuretics first, followed by reserpine, methyldopa, hydralazine and guanethidine-are the mainstay of treatment, although traditional Chinese herbal medicines are prescribed as part of the regimen. It seemed clear, however, that these latter agents were used for symptomatic relief rather than actual blood pressure reduction. At residential or factory clinics, the program for hypertensive care reflected the health care delivery system in general. Worker doctors, barefoot doctors and sometimes nurses or auxiliary health workers provided ongoing treatment after the initial diagnosis and initia-
MEDICINE,
tion of therapy had taken place at the “hospital’‘-which is really more like a medical clinic since it does not usually have inpatient facilities. In only 44 per cent of 600 patients begun in this program five years ago, has blood pressure control been achieved and maintained-a figure remarkably reminiscent of over-all 1J.S. experience. THE COMMUNE We visited a rural commune of some 80,000 inhabitants located 80 miles from Canton. The director of its health system, Dr. Pan, was formerly an urban physician member of a mobile health team who answered Mao’s call to “serve the people” 13 years ago by moving permanently to the commune. In a modest hospital, surgery, stomatology. obstetrics and general inpatient medicine is practiced. Although he is responsible for decisions about health programs, Dr. Pan is assisted by other doctors plus nurses, barefoot doctors and health orderlies, most of whom have been trained locally. In our briefing, Dr. Pan indicated that cardiovascular disease was the leading health problem in the commune but hypertension per se was not seen as a significant problem. The major public health project currently underway was commune-wide screening for thyroid cancer. Although a larger percentage of commune members have been screened, the yield has been minimal. The success of the undertaking, from an organizational point of view, was, however, felt to be gratifying. COMMENTS Conclusions drawn from these few random observations are hazardous in that we had no opportunity to discuss health care with any high-ranking public official responsible for health planning, although one of us (GGR) was able to interview comrades from the Canton Bureau of Public Health who were responsible for quarantine, parasitic disease and environmental hygiene respectively. Some observations, however, seem to have at least conjectural value in terms of their relevance to both the Chinese and American experience. In one generation, the people of China have leapt medically from conditions characteristic of the leastdeveloped nations to a position in which their mortality indices are indistinguishable from those of the most developed industrialized countries of the world. The diseases of deprivation which formerly ravaged preschool children have been replaced by the degenerative diseases which affect mature adult members of the population. Indeed, today in Peking, just as in New York, cardiovascular disease accounts for more than
SCIENCE
AND SOCIETY-ALIXRMAN.
READER
half of all deaths. In South China, however, there may still be found, malaria, Shigella and amebic dysentery, schistosomiasis and hookworm. Meningococcal meningitis and acute hepatitis are leading causes of death. A word of caution is in order concerning health and vital statistics in China. A particular hospital or even a large city appears to have fairly accurate statistics, but there is no central reporting mechanism above the province. The public health workers in Canton quoted Chairman Mao’s admonition to “settle things at the local level” and admitted that they did not communicate with Peking if they could help it. Their view of health statistics was more in terms of meeting production norms than gathering data on which broad planning decisions might be based. In the face of what is clearly a dramatic change in types of disease, we observed elements of a health care system strikingly out of tune with current health needs. The National Patriotic Health Campaign focused on past triumphs in sanitation and hygiene irrelevant to control of chronic disease, such as cessation of cigarette smoking, compliance with antihypertensive chemotherapy or prevention of the complications of upper respiratory tract infections. In sum, what appeared to be lacking were the components of a rational control mechanism to compile information about health conditions and to use that information to establish suitable priorities to assure that appropriate action be taken. Of course, a utopian situation in which reason governs health practice has not been achieved anywhere else in the world and certainly not yet here in the United States. But, the system for health care delivery in China, which has such great accomplishments to its credit, seems particularly well suited to meeting the long-term needs of patients with chronic, incurable, but treatable, diseases. Thus, it would be extremely paradoxic if the Chinese h’ealth infrastructure, which already links medical care to the fabric of community life, cound not be mobilized to provide ongoing health services such as those required for cardiovascular health. The point is, though, that the mere existence of necessary technology and a medical delivery system designed to ensure equal and universal access does not, in itself, guarantee solutions to all medical problems either in China or in the IJnited States.
REFERENCE Scrviccs in the Pcoplc’s Kepuhlic trf (China. hlcdicinc and Society in China. (Bowers JZ, Purcctl EF, e&l, New York, Itrst:ph Mac:y Jr. Formtlation. 1074. p 103.
1. Sitlcl VW: Ilealth
July 1979
The American Journal of Medicine
Volume 67
5
SCIENCE AND SOCIETY
Public Health in China: 1978 MICHAEL
H. ALDERMAN,
M.D
R society
apid change is characteristic of all aspects of Chinese today. It was against this background that we, as members of two medical groups, viewed China during 18 days in April and 15 in October 1978. In sum, we traveled more than 2,000 miles within China, viewed health facilities in seven cities and three communes. We visited hospitals, clinics, medical schools and the National Cardiovascular Research Center at Fu Wei Hospital in Peking. We met with probably 200 health workers, including physicians, nurses, barefoot doctors, worker doctors, health educators and administrators, and spoke, usually through interpreters, with perhaps 100. Despite the possibility that in such a huge country the distillation of our combined observations may bear little more resemblance to reality than the proverbial description of the elephant by the six blind men, we feel compelled to share our impressions of public health and medicine in China today. Like most other travellers, we were captivated by the warmth and openness of our Chinese collctagues and the esprit of the Chinese people everywhere.
ancl GEORGE
G. READER,
M.D.
does contribute to the apparently high prevalence of respiratory tract infection. There appears to be enough food for everyone, although staples including rice, meat and cooking oil are rationed to ensure their equitable distribution. An average family has meat two or three times a week at most. In northern China, noodles instead of rice are the staple, but wheat bread is being introduced. There does not appear to be serious malnutrition anywhere. Human waste is collected daily and used as night soil to manure the fields. Although it is supposed to be composted for at least two weeks heforc being applied, this practice is not always carefully followed in rural areas of the South. Garbage is also composted and applied to the fields. In some areas, solid waste is buried or burned. Air pollution seems to be a growing problem in industrial areas such as Shanghai and may contribute to the prevalence of cancer of the respiratory tract. Smoking is widespread, especially among men.
CHILD
HYGIENE Living conditions, as they relate to health, encompass water supply, clothing, housing, food and waste disposal. Although little potable water is available, the ubiquitous thermos bottle with hot water for tea, as well as the plentiful supply of beer and orange soda, appear sufficient to prevent waterborne disease. Except in the far north, and in some hotels and hospitals of western design, there is no central heating. As winter approaches, down-padded clothing becomes the main protection against cold and is often not taken off until spring. Bathing is accomplished in tubs, usually wooden, in mch household, or in some communes and housing projects, in winter, central bath facilities arc available. Housing is in short supply, but Chinese families have traditionally lived in what we might consider crowded conditions. Exposure to cold and crowding probably
CARE
Children receive exemplary attention. Trained midwives do the majority of deliveries in rural China. In the cities, deliveries are commonly done in the hospital where the mother is routinely sterilized after the second child. Immunizations are provided for the common childhood diseases except measles, and BCG vaccine isgiven to every child. After BCG vaccination, children are followed up by chest X-Ray at regular intervals. No child goes longer than 46 months without an examination. Rheumatic fever is said to have been controlled, but upper respiratory tract infections are common; there appear to be no facilities for culture of microorganisms outside of central hospitals. Otoscopes seem to be nonexistent. Head mirrors are in use in hospitals but not in clinics. Prevalence of middle ear infection is probably high since there is considerable mastoiditis. Rheumatic valvular disease is c:ommon. hut rheumatic fever is now believed to be imder control.
July 1979 The American
Journal
of Medicine
Volume
67
3
MEDICINE,
SCIENCE
TABLE I
AND
SOCIETY-ALDERMAN,
MORTALITY-United Shanghai 1972
Cause Cardiovascular (% ) Stroke lschemic heart disease Cancer (%)
States and China Peking 1977
31
United Stales 1975 52
53 24
19 -
READER
a
25
10 37
23
19.3
MEDICATIONS A wide range of modern drugs are available in hospitals, but in the barefoot doctor’s clinic in one commune only sulfathiazole and chloramphenicol were present besides a large number of Chinese medicines. The traditional medicines are said to be highly effective but are used empirically without any knowledge of dose/response relationships or basic mechanisms of action, although studies have begun in some centers on the pharmacology of these drugs. In addition to drugs prescribed in hospitals, patients may purchase a large number of traditional and western drugs, ranging from ginseng to colistin to cantharides, over the counter. ACUPUNCTURE
ANESTHESIA
Acupuncture has been used since about 1958 as a regular anesthetic for major surgery. It appears to be most popular in Shanghai, where surgeons claim it can be used in 98 per cent of operations. In Peking it is considered particularly useful for superficial (i.e., head, neck and thoracic) surgery and for some gynecologic procedures, but Peking surgeons believe it does not provide adequate relaxation for most abdominal surgery. Four operations were observed in Shanghai in the Cardiopulmonary Hospital, all using acupuncture. The patients were women in their 3Os, one with an adenocarcinoma of the right middle lobe, one with a patent ductus and two with mitral stenosis. Ten milligrams of morphine were given as premeditation. An acupuncture needle was inserted into the right forearm and 4 V of pulsating direct current applied. Induction required about 15 minutes. The patients remained awake throughout. Only the patient undergoing lobectomy required intubation. Oxygen was given intermittently. The patients appeared to feel no discomfort, sipped water and spoke with the acupuncturist. A main function of the acupuncturist during the operation was to provide a breathing rhythm for the patient. We were told that patients are admitted a week before operation to learn diaphragmatic breathing, much as is done in natural childbirth. The surgeons were deft and quick. With electrocautery there was little bleeding, and all the operations were completed in a little over z hours. A PUBLIC
HEALTH
CAMPAIGN
During our stay in China, the annual National Patriotic Public Hygiene Campaign was in progress. In Peking
4
July 1979
The American Journal of Medicine
Volume 67
we passed sound trucks exhorting the public to eliminate the traditional four pests (flies, rats, mosquitos and bed bugs), eschew public spitting, air their bedding and brush their teeth regularly. An enormous Sunday Parade had been held to publicize the theme of domestic hygiene. In Shanghai, retired workers waving banners lined the main commercial thoroughfares while bands played and huge posters announced the presence of health workers presenting displays where microbes could be viewed through microscopes. Unable to speak the language, we could not accurately judge public response, yet it was clear that very large numbers of people were directly involved in the campaign. It is true that flies are now rare in China; birds also have been virtually eliminated. A CARDIOVASCULAR
CENTER
In contrast to reports provided by Dr. Side1 in 1972, cardiovascular disease was found to have replaced cancer as the leading cause of death in Peking (Table I] [l]. The distribution of cardiovascular deaths was, however, considerably different in China compared with that in the United States. Strokes accounted for some 45 per cent of the total, and myocardial infarctions for less than 15 per cent. During a visit to the Fu Wei Hospital, Drs. Tao Sho-Chi and Lui Li Shang described results of their long-term observations of more than 100,000 persons who comprised the population of an urban industrial mill and a rural commune. In view of the increasing incidence of cardiovascular morbidity, and the known association of high blood pressure with stroke and heart disease, these investigators had begun studies of hypertension within their two communities. The prevalence of this condition was found to be about 7 per cent in the rural and 9 per cent in the urban group. These figures are based upon hypertension being defined as a 4th Korotkoff sound above 90 mm Hg. This technique is a more sensitive definition of hypertension than is the American practice and, therefore, suggests that despite the high incidence of stroke, hypertension is less common in China than here. A prospective study of antihypertensive therapeutic intervention for urban residents with diastolic pressures less than 100 mm Hg was begun in 1973. Western drugs-diuretics first, followed by reserpine, methyldopa, hydralazine and guanethidine-are the mainstay of treatment, although traditional Chinese herbal medicines are prescribed as part of the regimen. It seemed clear, however, that these latter agents were used for symptomatic relief rather than actual blood pressure reduction. At residential or factory clinics, the program for hypertensive care reflected the health care delivery system in general. Worker doctors, barefoot doctors and sometimes nurses or auxiliary health workers provided ongoing treatment after the initial diagnosis and initia-
MEDICINE,
tion of therapy had taken place at the “hospital’‘-which is really more like a medical clinic since it does not usually have inpatient facilities. In only 44 per cent of 600 patients begun in this program five years ago, has blood pressure control been achieved and maintained-a figure remarkably reminiscent of over-all 1J.S. experience. THE COMMUNE We visited a rural commune of some 80,000 inhabitants located 80 miles from Canton. The director of its health system, Dr. Pan, was formerly an urban physician member of a mobile health team who answered Mao’s call to “serve the people” 13 years ago by moving permanently to the commune. In a modest hospital, surgery, stomatology. obstetrics and general inpatient medicine is practiced. Although he is responsible for decisions about health programs, Dr. Pan is assisted by other doctors plus nurses, barefoot doctors and health orderlies, most of whom have been trained locally. In our briefing, Dr. Pan indicated that cardiovascular disease was the leading health problem in the commune but hypertension per se was not seen as a significant problem. The major public health project currently underway was commune-wide screening for thyroid cancer. Although a larger percentage of commune members have been screened, the yield has been minimal. The success of the undertaking, from an organizational point of view, was, however, felt to be gratifying. COMMENTS Conclusions drawn from these few random observations are hazardous in that we had no opportunity to discuss health care with any high-ranking public official responsible for health planning, although one of us (GGR) was able to interview comrades from the Canton Bureau of Public Health who were responsible for quarantine, parasitic disease and environmental hygiene respectively. Some observations, however, seem to have at least conjectural value in terms of their relevance to both the Chinese and American experience. In one generation, the people of China have leapt medically from conditions characteristic of the leastdeveloped nations to a position in which their mortality indices are indistinguishable from those of the most developed industrialized countries of the world. The diseases of deprivation which formerly ravaged preschool children have been replaced by the degenerative diseases which affect mature adult members of the population. Indeed, today in Peking, just as in New York, cardiovascular disease accounts for more than
SCIENCE
AND SOCIETY-ALIXRMAN.
READER
half of all deaths. In South China, however, there may still be found, malaria, Shigella and amebic dysentery, schistosomiasis and hookworm. Meningococcal meningitis and acute hepatitis are leading causes of death. A word of caution is in order concerning health and vital statistics in China. A particular hospital or even a large city appears to have fairly accurate statistics, but there is no central reporting mechanism above the province. The public health workers in Canton quoted Chairman Mao’s admonition to “settle things at the local level” and admitted that they did not communicate with Peking if they could help it. Their view of health statistics was more in terms of meeting production norms than gathering data on which broad planning decisions might be based. In the face of what is clearly a dramatic change in types of disease, we observed elements of a health care system strikingly out of tune with current health needs. The National Patriotic Health Campaign focused on past triumphs in sanitation and hygiene irrelevant to control of chronic disease, such as cessation of cigarette smoking, compliance with antihypertensive chemotherapy or prevention of the complications of upper respiratory tract infections. In sum, what appeared to be lacking were the components of a rational control mechanism to compile information about health conditions and to use that information to establish suitable priorities to assure that appropriate action be taken. Of course, a utopian situation in which reason governs health practice has not been achieved anywhere else in the world and certainly not yet here in the United States. But, the system for health care delivery in China, which has such great accomplishments to its credit, seems particularly well suited to meeting the long-term needs of patients with chronic, incurable, but treatable, diseases. Thus, it would be extremely paradoxic if the Chinese h’ealth infrastructure, which already links medical care to the fabric of community life, cound not be mobilized to provide ongoing health services such as those required for cardiovascular health. The point is, though, that the mere existence of necessary technology and a medical delivery system designed to ensure equal and universal access does not, in itself, guarantee solutions to all medical problems either in China or in the IJnited States.
REFERENCE Scrviccs in the Pcoplc’s Kepuhlic trf (China. hlcdicinc and Society in China. (Bowers JZ, Purcctl EF, e&l, New York, Itrst:ph Mac:y Jr. Formtlation. 1074. p 103.
1. Sitlcl VW: Ilealth
July 1979
The American Journal of Medicine
Volume 67
5
