Michelle Renshaw is the author of Accommodating the Chinese: The American Hospital in China, 1880-1920, a history of American medical missionary involvement with China, from the latter half of the 19th century through to the late Republican period of the early 20th century. The book, as we have mentioned before, is a must read for those wishing to understand China’s current medical system, and even more so for those interested in Chinese hospital.
Today we present part two of a two part our interview with Michelle (Part I is here). The whole of the interview was conducted by email after an initial phone conversation. On account of the fact that Michelle has recently returned from a trip to Suzhou, Jiangsu, where she toured several hospitals, including one that she profiled in her book, she was able to give us a fresh take on what she saw and she relays it to us here (See Part I).
Part two focuses on Michelle’s impressions of China’s ongoing reforms in the healthcare sector, and on the implications that the Chinese experience with health care during the past one hundred and fifty years has on Chinese views about the privatization of care. Michelle also talks to us about what this history and its impact on current Chinese views of healthcare may have on the private healthcare industry in China.
There is a famous dictum that has been elevated to the level of a sutra among Chinese physicians, beginning sometime in the 1980s. This dictum is that Chinese healthcare must “walk on two legs.” What this means is that the Chinese healthcare system should strive to provide the most modern healthcare available while also striving to provide healthcare that is affordable to all. The relevant context is that party cadres promulgated the dictum among doctors in order to quell entrepreneurship among doctors who had begun to extort very high prices for their services during the period of the first health reform at the beginning of the 1980s. In Accommodating the Chinese you describe the debate within the medical missionary hospital about how to charge patients, if at all, for the medical services. There is one group who believes that requiring payment of any kind would jeopardize the evangelizing goal due to the association that would be formed between the medical missionaries and capitalist/colonialist/imperialist exploitation, while other groups thought that payment was alright as long as it wasn’t excessive. There is a parallel between those concerns and “walking on two legs” – namely, that requiring too much payment would offend the sensibilities of the Chinese citizen.
I’m not sure that “offending their sensibilities” quite captures it: feeling as though one had been taken advantage of, and subsequent loss of face, might be more appropriate. Many patients targeted by private operators maybe ‘middle-class’ they don’t have unlimited funds and are aware of the current prices in the market-place. Before the implementation of the latest iteration of insurance cover, health care costs were a major cause of poverty and reason for not seeking timely care.
Do you think that there is a social aversion in China against the over-privatization of healthcare?
I don’t think it is ‘privatization’, that is, the ownership in private hands that is the problem so much as ‘market-driven’ health-care. As you noted, they experienced the consequences of ‘free-booting capitalism’ after the demise of the commune system in the early 1980s. When hospitals were required to be self-sufficient, even while being constrained in what they could charge for, patients felt, with some justification, that they were sold expensive drugs and subjected to tests they didn’t need. People were frustrated with high prices and believed that doctors were corruptly influenced by greed and pharmaceutical companies, hence the “walking on two legs” campaign.
I have to say I am bemused by potential American investors’ frankness as to their motive but, to an Australian ear, publicly saying that “we are aiming our services to the Chinese consumer that likes to buy a Gucci bag – a real Gucci bag” is off-putting. I can’t speak for the Chinese but a middle-class Beijing friend told me he could not understand why anyone would pay 10 times the fee charged by a public hospital where they will be treated by a top specialist just to go to a private hospital where the only advantage might be that the wait could be shorter.
How can the experiences of 1880-1920 enlighten us on this point?
Medical missionaries were clear that medicine was a tool and that their principal motive was evangelical, that is to gather souls. In this, incidentally, they largely failed. In the beginning missionary societies believed that a medical missionary should be a preacher first and a doctor second. By 1920 it was pretty well universally agreed that the balance of medical missionary work should tip in the other direction. It was when the emphasis turned to practicing good medicine that their long-term success was ensured and many of the first class hospitals in China today trace their roots directly to these early hospitals.
The latest American “missionaries” to China are corporations, again using medicine, but this time seeking profit not souls. Maybe the old adage that a good product that the customer wants and can afford will produce the sought after profits. Missionaries are notoriously patient – maybe that is their lasting lesson.
What questions do you find yourself asking about China’s current round of healthcare reforms?
There are many, but here are a couple.
1. [On] Pharma.
I observed patients, including toddlers, sitting in the 24-hour “infusion rooms” in Chinese hospitals hooked up to antibiotic drips. While I acknowledge that the government crackdown on the overuse of antibiotics might be “bad news” for Pharma it might be very good news for Chinese patients and the rest of the world threatened by drug-resistant bacteria.
I have been following the reactions of consultants and foreign big business to Chinese government strategies to limit drug prices. As an Australian health consumer, whose government successfully manages drug prices, I know the benefits that control brings. I doubt that America provides the bench-mark for best practice in controlling health-care costs.
2. Health Clinics and General Practitioners
The policy of re-establishing the system of “gate-keeping” clinics – this time staffed by GPs – with the aim of reducing costs and pressure on hospitals is a worthy one but I am a skeptical about its chances of success. I am watching to see whether China, which has been training specialists for the past 90 years, is going to be able to attract and train sufficient candidates when the lower-paid job is perceived as lacking the opportunity for promotion and status enjoyed by hospital-based doctors. I will also be interested to see whether patients will see the value in utilizing them, particularly when there is an accessible hospital where they can consult a specialist. It seems to me that the interests of both the medical profession and patients coincide in the continuing growth of the comprehensive public hospital and that that combination will be a powerful brake on change in behavior.
What questions came up in your research of the American Hospital in China that you still don’t have answers to?
There is so much we don’t yet know. For example:
Within the literature it seems to be accepted wisdom that Chinese women would not consult male doctors and that this explains why so many female medical missionaries were recruited. I am not sure that the evidence supports this thesis.
I would also like to know how the actual medicine practiced by medical missionaries differed from what they would have done at home? Did Chinese medicine influence their practice and if so, how? Were any of the methods or approaches they developed transferred to the west?
Thank you Michelle for speaking to us.
If you wish to contact Michelle, you can send her a message here.