The EconomistAugust 29th 2020 China 31T
he chinese languageis rich in concise, sardonic sayings,
many of which reflect universal truths. It also includes lots of
phrases steeped in a world view that is distinct to China. One such
is yi buguo erdai, meaning “no doctor’s child becomes a doctor”.
This may be accompanied by a cynical shrug, perhaps after reading
about the latest Chinese hospital boss arrested for bribe-taking or
a fresh scandal involving fake medicines. The saying is also used
on hearing news outlets describe another stabbing or assault of a
doctor at work—for fully two-thirds of doctors told the Chinese
Medical Doctor Association in 2017 that they had been attacked or
threatened in a hospital, often by their patients’ angry relatives.
Small wonder that in one survey after another, few want their
children to be doctors.
Elsewhere, doctoring is such a family business that journals of
medical ethics devote papers to the subject. One such study found
that one in five American medical students has a parent who is a
physician. In China the profession is neither very prestigious nor
especially well paid: even senior doctors typically earn just over
100,000 yuan ($14,500) a year—hardly a fortune in a big city.
Then came covid-19. Communist Party leaders have declared
their handling of the virus a triumph, and are willing to give doc-
tors and nurses a share of the credit. Much of China feels normal
now, even celebratory. Case numbers are so low that authorities
are easing strict lockdowns and border closures imposed months
ago, though they are in no hurry to dismantle digital tracing sys-
tems that oblige urbanites to scan qrcodes with a smartphone
when entering a public building or taking a train or aeroplane.
Early cover-ups, which saw officials in the city of Wuhan con-
ceal the severity of the outbreak for weeks, punishing doctors who
sounded the alarm, have no place in official narratives. Medals and
honours have, however, been bestowed upon selected, state-
approved doctors and scientists who prodded the central authori-
ties to act. A new art exhibition at the National Museum in Beijing,
devoted to covid-fighting medics, opens with a giant portrait of
Zhong Nanshan, a celebrated 83-year-old lung doctor who used his
seniority to reveal in late January, on national television, that co-
vid-19 was spreading between people. The doctor, depicted against
a stormy sky, his eyes brimming with tears, is captioned: “Commu-
nistPartymember, Zhong Nanshan”. Another artwork depicts
young doctors from an elite Beijing hospital taking a break from
volunteer service in Wuhan to express their patriotic fervour in a
letter to the party chief, Xi Jinping. The show is reserved for Chi-
nese nationals, so Chaguan has seen only photographs of his fa-
vourite work, a Tibetan scroll-painting, or tangka, showing three
figures in traditional robes prodding leering, cartoon-like corona-
virus spheres into a fiery pit, watched by a yak in a face-mask.
Propaganda about heroes in white coats has filled state media
for months. It seems to have resonated. Zhang Shuyang, dean of
China’s most highly regarded medical school, Xiehe, told state
television that applications to her college and its sister academy at
Tsinghua University, also in Beijing, are up 30% since last year.
Yet other experts on China’s health system express caution.
Praising heroic doctors from well-known, elite hospitals does
nothing to solve the big, structural problem with China’s health
system, and may even make it worse. Access to good care is shock-
ingly uneven, with a vast gulf of quality between big-city hospitals
and the rest. That prompts the public to seek care at a few, over-
crowded urban hospitals, sometimes queuing for days to see a
doctor for a 90-second consultation. What China really needs is
clinics in small towns and villages that people actually want to use.
Distrust of local medicine is well founded. In 2016 just 0.2% of
rural doctors in village clinics held at least a bachelor of science de-
gree in medicine. Even in township-level health centres, only just
under half of doctors in general practice (known as family medi-
cine in America) are university graduates.
China’s best medical colleges are trying to set eight years of
training as a norm. But despite schemes offering tuition-free med-
ical education to those willing to work in rural areas, most gradu-
ates want jobs in large cities. “You have got to develop adequate in-
centives for medical graduates to go back to the countryside and
serve the people,” says Tang Shenglan of Duke University in North
Carolina. Perhaps a third of medical graduates never practise as
doctors. Big-city hospital jobs are hard to land, and county general
hospitals struggle to recruit new graduates, who can earn more as
pharmaceutical sales reps. In the profession overall, “morale is not
high, honestly speaking”, says Professor Tang. Until China reforms
the way that hospitals are financed, even doctors with “good
hearts” will face pressure to earn revenues for their department
(and performance-related pay for themselves and their col-
leagues) by over-prescribing drugs, tests and surgical operations.First, do no harm
Liu Tingfang, a professor of hospital management at Tsinghua
University, worries that relations between anxious patients and
harried hospital doctors are “not nice any more”. To repair them,
the public needs to believe that hospitals care about more than
making money, he says. For doctors to be respected, they must be
better paid and allowed to seek more than one legal income
source, as in the West. Otherwise, post-covid, “things will go back
to where they were,” the professor frets.
Another Chinese saying holds that “seeing a doctor is hard and
expensive”. Working patiently to retire that phrase is not as excit-
ing as staging patriotic exhibitions about covid-fighting heroes.
But it is the key to reducing cruel inequalities that too often make
sickness a financial catastrophe, and poverty a death sentence. For
years China’s priority has been shiny high-speed trains, Olympic
stadiums and aircraft-carriers to awe the world. A true superpower
would build a health system to match. 7Chaguan System, heal thyself
Party praise for covid-fighting doctors does little to fix China’s ailing health system