Failing Health

In the early hours of April 14, 2012, Zheng Yanliang cut off his right leg. Racked by pain but unable to pay for an amputation, the corn farmer bit down on a back scratcher and severed his limb with a hacksaw and a fruit knife. It took 20 minutes to grind through the bone.

Much is astonishing about Zheng’s ordeal—not least that he survived. Zheng, then 46, was an otherwise healthy man, wiry and limber, when excruciating leg pain sent him to a local clinic. The doctor diagnosed him with arterial thrombosis and said blood was barely getting to his lower limbs. He needed an amputation.

Wanting the best possible care, Zheng and his wife traveled from their dusty village of Dongzang in China’s eastern Hebei province to a public hospital in Beijing. The hospital wanted 300,000 yuan, or about $48,000, in cash as a deposit, Zheng says. He made about $400 in a good month, so he went home and waited to die. Months passed. Maggots emerged. By the time he put sawtooth to skin, he says, the pain was so searing that he was happy to see his leg gone.

When Zheng’s story hit the headlines last fall, it turned the farmer into a folk hero. His woes resonated among ordinary Chinese. Like Zheng, they are frustrated with the faults of China’s health care system: long waits, shoddy service, high costs. “The [Zheng] case epitomizes the sustained failure of the government to provide a solution to the problem of affordability and access,” says Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations.

While the U.S. grapples with the implementation of Obamacare, China is struggling with a health crisis of its own. The “barefoot doctors” that tended to the poor during the Mao Zedong era long ago gave way to a patchwork of private and public care of varying cost and quality. Though the cost of medical care is still low compared with the U.S., it is out of reach of many. The rich and connected can get to the best hospitals and pay cash up front. Ordinary families have to save large amounts of money for medical bills or are forced to take out loans.

Many clinics are dirty and crowded. Patients sometimes wait hours to see a frazzled, underpaid doctor for a minute or two. To make up for their awful pay, some doctors accept bribes, often in the form of cash-stuffed envelopes. There’s little legal protection for either side when things go wrong. Violent attacks on doctors have become common.

The ailing health care system hurts the economy too. More than 35 years into the great experiment known as “reform and opening,” China’s economic engine is slowing. The ruling Chinese Communist Party believes that to keep moving forward—and keep citizens happy—it must rebalance the economy, shifting the focus from low-cost exports to domestic demand. That means persuading families to spend. Right now, average households save more than 50% of their income, in part to guard against unexpected medical bills. The World Health Organization (WHO) estimates that the proportion of the Chinese population over 60 will reach 15% next year and jump to 24% by 2030—making medical insurance an economic priority. Sick workers, moreover, aren’t productive.

In 2009 the central government pledged about $173 billion over three years for public health care. The state vowed to provide basic medical insurance for all Chinese, regardless of where they lived, or what they earned, by 2020. This includes China’s underserved rural population, which, at some 800 million, dwarfs the population of the U.S. Officials report that almost 100% of Chinese are now insured (and happily note they achieved this before the U.S.). Government insurance now covers more of each visit, including up to 70% coverage for some serious illnesses. But stop any person on the street, and they’ll tell you that the scope of the insurance is spotty. “They’ve got the who covered,” notes Dr. Bernhard Schwartländer, WHO’s representative in China. “Now they need to work on what is covered and how much it costs.”

A Sick System

When it comes to health care, Dr. Liu Yinglong has seen it all. Born in the early days of the People’s Republic, the spry, mop-haired 62-year-old has been a surgeon for 40 years and a practicing doctor for more. His career has taken him from country clinics in Mao-era Inner Mongolia to medical school and on to jobs at some of the country’s top hospitals. He now heads the department of pediatric cardiology at Beijing’s Anzhen Hospital. The walls of his corner office are thick with commendations.

What’s changed over the years? “Everything,” says Liu. In his lifetime alone, China’s health care system has gone from semipublic to private to somewhere in between. In the early 1950s, when Liu was born, Mao laid the foundations for a state-sponsored system designed to keep workers well. The Cultural Revolution saw many health officials and doctors sent to labor in the countryside, while farmers were given basic medical training and sent forth to heal. By 1976 there were 1.8 million “barefoot doctors” tending to rural Chinese.

During China’s post-Mao economic boom, government health care spending as a percentage of GDP dropped from 1.1% in 1980 to 0.8% in 2002. (In contrast, 2002 U.S. government health spending accounted for 6.7% of GDP.) As the communal system of the Mao era crumbled, medicine, like much else, became a for-profit business, and more and more Chinese found themselves without care. For rural people especially, out-of-pocket medical expenses led back to poverty.

When the government tried, and failed, to cover up the 2003 SARS epidemic, public anger boiled over. The leadership realized that health was a question of social stability—Beijing’s abiding priority—and pushed ahead with reform. From 2006 to 2011, the number of people with some form of insurance jumped from 43% to 95%, and total health spending more than doubled thanks to renewed interest and investment from the state. “This is unprecedented, globally,” says Zhang Shuo, a health care specialist at the World Bank. “We have got to give them credit.”

More of Liu’s patients now get a portion of their bills reimbursed. But even Liu, a party member, says he feels the system straining. Top-tier public hospitals like Anzhen are packed, their scuffed, fluorescent-lit hallways lined with restless patients. The type of complex heart surgery Liu performs is not available in most of China—and even if it were on offer, few parents would trust a lesser-known, local facility. To meet demand, Liu sees 10 to 15 patients before 8 a.m. He works seven days a week. “In China, there just aren’t enough good hospitals,” he says.

Nor are there enough good doctors. And even though they are in short supply, doctors make a pittance. Most work for public hospitals and are paid like civil servants, usually to the tune of about $495 to $825 a month. They make more when they order tests or prescribe drugs. A 2011 survey by the Chinese Medical Doctor Association found 96% felt underpaid, and 80% did not want their kids to follow their career path. Declared the British medical journal Lancet in May 2012: “China’s doctors are in crisis.”

Under the Knife

The door to Dr. Qin’s clinic is wide open. It is winter in Changsha, the humid capital of central Hunan province, and it is about 10°C. But there is no heat. Mao, a Hunan native, decreed that only half of China—cities north of the Huai River—needed heating, so the air inside is about the same as on the street. Qin, who wants his given name withheld for fear of local authorities, wears a wool jacket. His wife, the nurse, wears her white smock over a knee-length down coat. Their snow-suited daughter plays on the floor with a neighborhood dog.

Qin is the closest thing to what Americans call a family physician, in that he treats people from the neighborhood with non­urgent conditions. A consultation comes to just shy of $10, plus the cost of whatever the doctor prescribes. That kind of money doesn’t buy much, equipment-wise, and it certainly will not make you rich.

His biggest concern, however, is not money but safety. Three years ago one of his patients had an allergic reaction to the Chinese medicine he prescribed. He survived but demanded compensation. When Qin refused, the man returned with a crowd, Qin says. Terrified, he gave him cash on the spot. “What choice did I have? I was scared they’d kill me.”

Without proper malpractice insurance or fair courts, there is little protection for doctors or patients when procedures go wrong. (Or when people think they do.) Because local authorities generally are wary of reporting disturbances, solid figures are hard to come by, but one survey by the China Hospital Management Association reported that from 2002 to 2012, attacks on Chinese medical staff jumped an average of almost 23% each year. By the end of that span, the reported per-hospital average was 27 attacks a year.

In one high-profile case, Dr. Wang Yunjie, a 46-year-old ear, nose and throat specialist, was stabbed to death on the job. The killer, a disgruntled patient, entered the hospital looking for his doctor but could not find him. He charged at Wang instead. After Wang’s death the government vowed to beef up security, promising a security guard per 20 beds. One hospital started training workers in kung fu.

Neither measure has managed to keep doctors safe. In March a young doctor from Guangdong province was paraded around by an angry mob after one of his patients died. Not long after, a 20-year-old nurse was beaten with an umbrella until she lay motionless on the floor. The attacker was a government official irate that her daughter was forced to share a room with a male patient. Morale could not be lower. Responding to a story about the violence, one Chinese netizen wrote, “If my child dare choose medicine as their major, I would break their legs.”

Back to the Future

China’s government insists things are changing. Officials from the Ministry of Health and Family Planning declined repeated interview requests, but in a written reply to questions from Time, reported “significant progress” on the 2009 health care reforms, particularly in the realm of public health insurance and improving local facilities. The ministry reports that each village now has a clinic, and each town, a hospital.

In a March 5 speech to China’s National People’s Congress, delegate Dr. Zhong Nanshan, a respected physician and veteran of the SARS outbreak, was less upbeat. In less than 10 years health spending has jumped from 3% to 5% of GDP—a “great effort,” he said, but still less, by GDP, than Afghanistan. Doctors are exhausted and disillusioned, he said, and the general public still finds it difficult and expensive to receive care.

Take farmer Zheng. When his local hospital couldn’t treat his leg pain, he went to the city. If he had the money to be admitted, the rural insurance scheme may have reimbursed some of the costs of his care—an improvement over years past. But he did not have the money to get in. So he went back to his concrete courtyard home and cut off his leg.

For Zheng, help came only after he contacted a local reporter. When people heard his story, donations from party cadres and concerned citizens flooded in. A year and a half after the DIY amputation, his other leg, which was also damaged, was removed in a hospital free of charge. He greeted reporters at his home in Dongzang village in the presence of local officials who, while declining to introduce themselves, made a point of reminding Zheng how much the authorities had done to help. Was Zheng satisfied with his treatment? “I’m just a farmer,” he said. “I don’t know about such things.”

When another blood clot landed Zheng in the hospital, reporters were forbidden from asking him questions. In a hallway patrolled by uniformed security personnel, Zheng’s wife told Time they needed money for new bills, prosthetics and rehab. “It’s a very bad situation,” she said. “We are running out of time.” So is the rest of China. —With reporting by Chengcheng Jiang and Gu Yongqiang