The Ripon Forum

Volume 0, No. 0

Oct - Nov 2007 Issue

From Barefoot Doctors to Red Envelopes

By on November 11, 2015 with 0 Comments

China’s health care system is weighed down by a legacy of government control


As Beijing prepares to host the Olympic Games in August 2008, the entire People’s Republic of China is preparing for a celebration of its newfound economic and political preeminence. Schoolchildren across the country are taking part in performances devoted to the advent of the Games; signs urge pedestrians to “promote Chinese culture” by being more polite; and whole neighborhoods are being razed in order to make way for shiny new stadiums and high-rise apartment buildings. 

These would all seem to be indicators of China’s great progress and ascent as a developed nation. But in some respects, China still has a long way to go. Pollution, human rights, freedom of the press: all have received attention in the Western media as areas of conduct for which the People’s Republic has received international censure. However, one of the most critically underdeveloped aspects of Chinese government and society – and one from which we have much to learn in the U.S. – is something that we often take for granted: the availability of basic health care. 

A baby with respiratory problems and an adult with high blood pressure wait to see the doctor in Li Jia Wa Zi village in China in April 2006. Ma Dong Ji, center, is the only doctor practicing in this mountainous region. He travels by scooter and receives a portion of medicines from the government, the remainder coming from private NGOs.

A baby with respiratory problems and an adult with high blood pressure wait to see the doctor in Li Jia Wa Zi village in China in April 2006. Ma Dong Ji, center, is the only doctor practicing in this mountainous region. He travels by scooter and receives a portion of medicines from the government, the remainder coming from private NGOs.

The average American would find a Chinese hospital surprisingly dirty, crowded, and dark. It is not unheard of for disposable syringes to be reused over and over again without disinfection, IV drips to be filled with fake protein plasma, and rat poison to be found in hospital food. The hallways are full of families who have traveled a long way from their home villages to visit a city hospital. They must pay exorbitant prices in order to receive a very low level of care. The situation for most patients has become so dire that in November 2006, over two thousand people in Sichuan Province rioted in anger at the high cost and low quality of health care available there. 

How did health care in China get this bad? And could it happen in the U.S.? 

The case of China provides us with a unique and important example of a country that has functioned under both socialized and free-market medicine. Medicine in China is in a sorry state today in part because of the government’s longstanding reliance on a national health care system – one that failed to provide advanced health care to its citizens and overburdened the national economy. In studying the evolution of China’s health care system, American policymakers can better understand the risks involved in both systems as they consider the prospects of universal health insurance in the U.S. 

China’s health care infrastructure has its roots in Communist policies of the 1960s and 1970s that gave universal but basic medical care to the entire nation. In the early days of the People’s Republic, Mao Zedong set up a highly effective system in which “barefoot doctors” were given a minimal amount of medical training and sent into the countryside to treat villagers with a combination of modern Western and traditional drugs. In urban centers, free clinics and hospitals were set up for citizens. 

Communist health care demonstrated that nationalizing medicine could be accomplished with relative facility but totally modernizing it was a much more difficult and expensive task.

The government’s emphasis was on making basic public health available to as much of the population as possible – and to an extent, they succeeded. Thanks to the work of barefoot doctors, there was a dramatic improvement in basic care availability. The life expectancy of Chinese citizens jumped from 35 to 68 years between 1952 and 1982. Citizens had access to Western medicine for the first time in many rural areas, and infant survival rates surged. In fact, the rapid advances in quality of care made under Mao are considered one of the chief administrative achievements of the Communist regime to date; economist and Nobel laureate Amartya Sen has touted the system as a model of socialized medicine. 

However, China’s national health care system demonstrated some characteristic pitfalls. For instance, during the Cultural Revolution of the 1960s, many surgeons and advanced specialists received censure for their elite social standing, and were sent to rural labor camps for “re-education.” Uneducated revolutionaries were left in charge of China’s national health system, with correspondingly disastrous results. Professional schools were shut down, and an entire generation of medical students was barred from receiving a suitably rigorous education. 

The horror stories of doctors in the Cultural Revolution may seem extreme, but their implications are applicable to a broader perspective on universal health care as we consider an American plan for nationwide coverage. While instituting national health care in the U.S. clearly would not involve the mandatory assignment of medical leaders to rural fieldwork, it could have a detrimental effect on American health care professionals. In a universal health care scheme, for example, U.S. doctors would face the risk of losing their salaries and clinical autonomy to a big government bureaucracy that could eventually dictate who gets seen, at what time, and what course of treatment to take. 

Perhaps the most important point for American policymakers to consider is that the successes of universal health care in the U.S. would be limited by a resulting lower quality of medicine. Communist health care demonstrated that nationalizing medicine could be accomplished with relative facility, but totally modernizing it was a much more difficult and expensive task.

The old Communist system of medicine died out in the wake of Mao Zedong’s death and Deng Xiaoping’s rise to power, when the government moved to privatize many state industries in the 1980s and 1990s as part of a push to modernize the economy. At this time, the People’s Republic abandoned much of its financial support for medicine. With only minimal official control or support, the costs of medical care skyrocketed up to market-competitive levels while its quality remained low – resulting in the dirty, crowded hospitals still functioning in many cities and rural areas today. 

Furthermore, rampant corruption was soon pervasive in hospitals and clinics. For instance, the government’s attempts to keep prices artificially low created a common situation known as “the red envelope” in which surgeons often demand extra payment from a patient before performing a procedure; the bribes are handed over covertly in traditional red packets filled with cash. 

The deplorable situation of China’s market-based medicine ultimately has its roots in the nationalized medicine of the 1950s and 1960s. As a state-run system, health care had grown too financially burdensome for the Chinese economy to support. As procedures became more advanced, costs rose, so that privatizing medicine merely shifted the growing cost burden of increasingly advanced care from the government to the people themselves. 

Where the Chinese government did retain some control over the costs of medicine, the result was disaster. When state-run medicine was dissolved, local governments were left with the responsibility of providing health care to citizens; with fewer resources available, these administrations could not afford the hospitals and health care facilities that the national government had provided. Private entities bought many of these facilities and began to provide health care at increasingly high costs. Meanwhile, Communist work units were dissolved as part of a push for privatization of industry, and the universal health insurance system that had been in place until now was also totally dismantled. 

According to Princeton economist Gregory Chow, the result was that the catastrophically low supply of available health care could not meet the growing population’s demand for it, prices skyrocketed, and subsequently a vast percentage of Chinese workers – especially in rural areas – ended up without minimal medical access. In short, the government’s retention of partial control over health care contributed to the poor quality of medical care available today by manipulating the “free-market” health care system. 

What lessons can U.S. lawmakers learn from China’s failed experiences with state-run and market-based health care? One is that they must not underestimate the sheer cost of socialized health care. Just as China’s national economy couldn’t support it, our government faces the prospect of limiting the amount and quality of routine care available to American citizens if it chooses to take control of the country’s medical system.               

Another important take-away message is the more grievous error of mixing two disparate systems of health care; as China’s example demonstrated, applying market principles to socialized medicine resulted in a severe discrepancy between the supply and demand for health care with disastrous consequences. For U.S. policymakers attempting to achieve the opposite transition – to nationalize a market-based system of health care – the consequences could be equally severe. 

As Congress tackles this issue, it must take care not to sicken our already-struggling health care system by reforming it too hastily – and more importantly, it must not forget that the health of the American people is at stake.   RF


Mary A. Brazelton is a student at Harvard University and editor for the school newspaper, The Crimson. An editorial assistant at the Ripon Forum this past summer, she is completing her undergraduate thesis on the history of American medical education in China. 

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