Tuesday, June 15, 2010

Teaching in China

Just back from teaching for the second year in Duke University's joint (along with Peking University) certificate in Global Health, held in Beijing, on the campus of PKUs health science campus. This is the same campus with PKU's "Third Hospital" and just inside the fourth ring road, about 5 minutes by taxi (or 45 minutes depending on traffic) from the Olympic village, Bird's Nest stadium, the water cube, etc. Professor Yan Guo directs the certificate from PKU's end and she is a delightful colleague, who got her start in public health and medicine as a barefoot doctor in rural China.

Around 40 students from all over China took this course. Some of the students were still full time students, while others were physicians, epidemiologists working for the Chinese CDC, and the Office of Quarantine and international travel; the folks who were front and Center dealing with the H1N1 virus and China's response last Summer, and other organizations.

I was teaching a course in comparative health care systems....essentially an overview in financing and structure of how nation's around the world deal with the two 'laws' that govern all health systems in the world: (1) everyone eventually dies; before that (2) the healthy subsidize the sick. The essence of health policy is figuring out how (2) above is done. We began as I always begin my comparative course at Duke, by saying that you cannot copy another countries health system, simply because such systems exist in a particular historical and cultural reality, time and space. But, it can be useful to see what other nation's do, and how it seems to work for them.

China recently announced a plan to move toward covering all Chinese persons with health insurance in January, following 3 basic guiding principles: (1) improve health status; (2) spread financial risk/expand insurance coverage of some type; (3) do 1 and 2 in a manner that improves satisfaction of the Chinese people with their health care and health care system.

China is profoundly on a 'different part of the curve' than is the USA in beginning their reform. The per capita expenditure on health care in China is around $400, with an avg. Life expectancy at birth of around 73 years; the USA has per capita expenditures of over $8,000 per year with life expectancy at birth of around 78 years. So, one thing that China plans to do is spend more, perhaps even much more, on health care services. And they are at a point at which increased expenditures will likely pay off with large health status gains quickly.

As with any per capita expenditure, that doesn't mean that each person gets exactly $400 spent per year on their health care. China probably has upwards of 500 Million people living in very remote rural areas where expenditures are more like $5 per capita (the USA has 310 Million total people). In the large cities of Beijing, Shanghai, and Guangzhou (up the Pearl river from Hong Kong) there are well developed health care delivery systems for persons with either government civil service or private employer based insurance. I think most Americans probably assume that a Socialist nation must have a one-size fits all top/down health care system, but it is really quite the opposite. Many different arrangements, depending upon geography, history, working status and the like. A very common phrase used by students in the course last week was 'we will have to have flexibility to work it out according to local circumstances.' This was especially true when students talked of the rural parts of China. Again, this is the exact opposite of what most Americans would assume.

And Professor Guo explained to me over dinner one evening that at the founding of the People's Republic of China, that the health policy from Mao Tse-Tung held that especially in rural areas, the local people had to decide exactly what type of system they wanted, and they had to fund it themselves. This lead and has lead to wide disparities and spending levels across parts of China, and particularly across different rural portions of the nation. And allowing such local variation and 'working it out' seems to clearly be a part of China's future in health policy.

We talked a great deal in the course about different ways to finance health care services and to collect and pool money (how the healthy subsidize the sick; same idea as car insurance, by the way, and in one sense is simply the definition of insurance). One tremendous demographic change that is underway is China's relaxing of the one child policy. A large increase in the size of a birth cohort would make payroll taxes an attractive way to increase spending, especially for older persons. We walked through the downsides of this approach, especially if later a one child policy is restored....that would make the baby boomer generation look like a small event.

A few other cultural observations, some that relate to health policy, others that do not. First, I enjoyed walking and running in the mornings and evenings and tried to use this time to explore and 'people watch.' There is a huge urban park nearby the PKU health sciences campus and at night, and especially sunday night, there are thousands of people out doing vaguely wholesome things like Karaoke, line dancing, hackey sack, a 50 person brass band playing Presbyterian Hymns, and people singing patriotic songs.

Second, in the mornings, there are many older persons out doing Tai Chi, oftentimes in large groups, especially of women. One thing I admired about this was the seeming lack of self consciousness of the people in doing this in public....I think Americans would feel quite self conscious if out doing such.

Third, there was an empty lot nearby the campus last August when I was there and last week there was a 20 story building there. The rate of construction and development is fast, and there was a construction sight nearby that I am fairly sure was working 24/7.

Fourth, last week had some very large economic events, namely a strike at a plant that supplies Honda with parts for Accords in a southern industrial city. The government appears to have tolerated this strike and to have essentially said that the workers have a point. This along with the widespread report of the doubling of wages in an iPhone factory that had many person's commit suicide appears to signal that the Chinese people are interested in reaping more of the benefits of their rapid economic development. And that the Chinese government either agrees and/or views this as inevitable. This is not surprising, and it part of a transition of China toward a higher income society.

Fifth, I noticed that most obese person's that I saw in China in my walks were young (elementary and middle school age kids). There are some alarming statistics about type II diabetes in China and India and some evidence that type II is onsetting among persons who are not very obese and that it be less amenable to diet and exercise as is the disease in the US. This is also a part of the transition of China to a higher income society.

Sixth, my colleague from Duke, Kate Whetten, taught the course Introduction to Global Health, which is essentially an introduction to health care in low income nations, as well as to a focus on health inequalities in higher income nations. The students were slower to be convinced of the need or benefit of China being involved in the rest of the world. We talked about some of the issues related to criticism of the Chinese government for being slow to respond to the Haiti earthquake...simply put, as China becomes more of an economic leader, the rest of the world expects them to be involved in the rest of the World. My biggest conclusion for the students last week was that China has a tremendous opportunity to not only reform its own health care system, but to be a model for the low income nations of the world who also would like to move to expand financing and expenditure on health care services. Because China is such an economic power, with lots of central infrastructure and ability to implement new polices (it will be slightly easier for Hu Jintao to get what he wants in health reform that it was for President Obama), if China will evaluate what happens and share this with the rest of the world, they have a great chance to be a model and a guide for the nations of Africa, Asia and South America in health reform.

Seventh, they don't have Chinese John Wayne. The hotel I was in only had 1 English TV station and you can only take so much of a business news station so I watched some war movies (there were two or three stations that always had war movies on, with Japan being the primary adversary). The bottom line that was easy to pick up was that the Chinese hero always seemed to die, the city was laid waste, and the concluding scene was one of lament. I kept waiting for the Chinese John Wayne to show up, but he does not exist.

Similarly, last year we went to Chinese opera at the 'egg' which is the name (not the actual name, but you see why they call it this) for the national opera house down by Tiannamen Square. It was a story about a man and his daughter traveling the silk road and his daughter was kidnapped by Middle East traders and she was taken away and married into Middle Eastern royalty. The dad searched for her his entire life and when he found her, filled with rage, he killed her husband, the Prince. Of course, this was his daughter's husband, and filled with sorrow, she killed herself and the story then just ended.

Compare this to the new movie the Karate Kid which I took my kids to see on Sunday....there was never any doubt who would win the last match. If this was a Chinese movie, the karate kid's leg would have been broken, the bad teacher would have killed Mr. Han, and the mom would have committed suicide due to the shame of her son's loss. There is a profound cultural difference between the USA and China in the stories that we tell about ourselves. I am not sure exactly what it means, but I am pretty sure it is important to understanding the relationship betwen the USA and China.

Finally, my bottom line take away from two trips to China and my readings about China is that China defies categorization. It is a jumble of contradictions and unlike any place else in the world. It is simply China. And in thinking about my kids future, when it comes to picking a foreign language to learn in school, there are only two choices that make sense: Spanish or Chinese.

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