School’s Out – What Chinese are talking about … (2)

The cult of Xi – from the Little Red Book on Mao Zedong thought to the nightly quiz show on Xi Jinping thought 

extolling Mao with the little red book; and 

extolling Xi with the tv quiz show 

Source: https://www.bbc.com/news/blogs-china-blog-45728131   A nightly tv show features students vying to be the one who knows most about the life, speeches, and travels of the current dear leader and Marxism.  This is a game show,  but there are no prizes for winners.  That must be why tv ratings are so low. 

As you know, I have some acquaintances from the Chinese government, in several different provinces and in some state owned businesses and universities.  All have pretty good jobs, at mid-level or higher.  A few are moving beyond a middle mid-level, perhaps chu bu ji, to higher reaches ting bu ji, as party leaders in districts or counties or university departments. 

Over the last five years, many expressed concerns about the direction of current Chinese governance, in much the same way that Americans look askance at the machinations of the Republican party and the orange-haired baboon (hat tip to Brad DeLong for the descriptor).  A common theme in China is the return to the fears and terrors of the Cultural Revolution.  Most of my acquaintances were born in that era, and have stories from their parents and families and colleagues.  The disappearances, the arrests now for corruption on actions that until recently were standard operating procedure, the personality cult of Mr. Xi, the demands for ideological purity, the lack of procedural rules that makes accessories to crimes out of officials just doing what they are told to do, the double binds that crop up all too frequently – if I do this thing, it will be illegal;  if I don’t do this thing, my career will be over – all are chilling reminders.  I will detail some of these fears in a future post.

The new era affects CCP members in their most cherished place – their families and kids. 

Among the recent developments in the last couple of years is passport retention by the Discipline Inspection Bureau for all mid-levels.  Prior to about 2013, Chinese officials going abroad could use either of two passports – a government official passport, which was always held by the Human Resources Department of their workplace, or their own private passport, which individuals retained, as we would do in the US.  Now, even the private passports are being held by the Discipline Inspection Bureau jiwei for some midlevels and above in at least some places.  I am told this policy is active in Hubei Province; not sure where else as of October.  It was not in effect in Zhejiang in June.  And some of my acquaintances – more than a couple – are worried that they might be unable to get out of China in the future.  Travel to the US is much more restricted on the Chinese side, and this was the case before the US 2016 election.  Chinese with kids in college in the US no longer get automatic approval to go out to see their kid graduate, notwithstanding the further restrictions on students and their families from the American State Department.

So what to do?  This is not a matter of trying to get illegal gains out of China.  These concerns are being expressed by good public servants who wish to retain options for retirement or school choices for their kids. The government has made it more difficult to move money out of China.  For the past twenty years, that was the safety valve for wealthy families- buy the house in London or Sydney or New York or San Francisco or Vancouver or Seattle, let the wife and kids live there, and at some point, retirement or the need to get out, join them (the US has no extradition treaty with China).  In 2012, Lin Zhe, a professor from the CCP’s Central Party School and a member of the National People’s Congress, said that 1.18 million senior officials’ spouses and children had emigrated between 1995 and 2005.

There are still ways to get money out.  Now, getting the people out is becoming more risky on both ends.  It is reported that senior government officials (perhaps at the provincial vice minister level or higher) will no longer be able to send their children outside China for education. Secret order to bar students from going out  China Said to Issue Secret Order Barring Senior Officials’ Children From Studying in US   This article notes that –

At a Senate Committee on Foreign Relations hearing on July 24, Dan Blumenthal, director of Asian studies at the American Enterprise Institute (AEI), recommended that the U.S. government impose visa limitations on the children of the CCP elite as a means of economic pressure.

AEI is a fairly right wing organization, and in normal times there would be no reason to think that its recommendations about visa restrictions would be considered.  However, we are not in normal times.  Good thing that Xi Mingze was able to get out of Harvard by 2014.  Today, she might not have been able to go out, or to get in. 

One of the few known pictures of Xi Mingze from her time at Harvard.   Source: https://images.firstpost.com/wp-content/uploads/2015/02/Xi-daughter-Twitter.jpg

Among many other worries, ability to go out for education is a worry for some smart and thoughtful Chinese officials and business people and academics.   Good thing Canada is still available. 

Libertarian Health Care

November, 2012 and updated 

Personal responsibility and preservation of power .. 

This was written just before and after the birth of our son, and was my take on the medical system.  I could not vouch personally for more than a few hospitals, perhaps six to eight, but stories from over the years, including doctors being murdered by enraged patients or family, confirms that my views expressed here are representative. 

What I saw every day –

Source: Gilles Sabrié, The New York Times at
https://www.cnbc.com/2018/10/01/chinas-health-care-crisis-lines-before-dawn-violence-and-no-trust.html

Just for fun, I looked online for stock photos of Chinese hospitals, doctors, and patients.  This site below has dozens of photos of what I never saw any day at any time.  Take a look, just for fun –

https://www.istockphoto.com/photos/china-hospital?sort=mostpopular&mediatype=photography&phrase=china%20hospital

My article below is from 2012, but not inaccurate now for that.   The Systemic problem cannot be solved by Mr. Xi, regardless of how stringent the anti-corruption campaign becomes.  It is common for people to offer hongbao (red envelopes) as gifts to doctors, teachers, business associates, and government officials from whom one would appreciate a good result.  The anti-corruption campaign does not change that behavior, nor does it change the grinding down of people as they try to obtain medical services. The picture below is representative of the typical room in the pregnant women’s hospital.  Four or five women side by side in a room, before and after the birth.  The VIP room – a single room – might require a hongbao.

Bribery serves as life-support for Chinese hospitals.  Arku Jasmine.  Graphic Online, July 24, 2013.https://www.graphic.com.gh/international/international-news/bribery-serves-as-life-support-for-chinese-hospitals.html

Those who followed my reporting over a span of years noted that my attitude in China changed when Qing became pregnant.  As I read back, that seems right.  My concerns then became about more than head colds and what amazing stimulus was I going to experience next week.  I was in the day-to-day lived experience of 1.3 billion other people.  Oh – one more thing.  Now, in 2018, there is no evidence that Keynes is the author of the quote below.  So, I should say, attributed to Keynes by Samuelson. 

Calling All Libertarians!

A couple of years ago, I wrote about Brenna and I going to the hospital to check on a chest and throat cold, and I described how easy and efficient and inexpensive the experience was. Now, I find myself in the position of Keynes when challenged by a political rival for changing his views on some issue of current affairs, retorted, “When the conditions change, I change my mind. What do you do, sir?”

I wrote a couple of weeks ago about the preservation of the System in hospital design.
The System design, for control and power, is preserved. And really, power conservation is not so unusual. But what I want to write about now is what accompanies power conservation, and that is the conservation of stupidity and laziness and acceptance of the status quo and “that’s not my job” attitude, even among people who are otherwise reasonably intelligent and have at least some modicum of training. And how the System allows for that. The System requires grinding people down.  The tools are mystery, lack of information, long lines to receive – not service, but a ticket to get service later.  Lack of information is the key.  When people do not have the ability to make sense of the System, whatever it is, they make up stories, including stories about leader power and efficacy of at-home remedies. And when people do get information from an official source, they have to choose – to rely on that message as Truth, or mistrust it as they have learned a thousand times before.  In the Chinese medical system, one confronts official mystery head-on.

In 2012, there began some noise about western hospitals looking to go to China – presumably in search of profits, not better health care for the world.  Even at that time, I thought – from my completely uninformed position in the American and Chinese medical markets and systems – that this was a poor plan.  To come in to a System, to have one entry point in a complex arrangement of sinews and choke points and flows of goods and patients and money – and expect to either reform the System or extract profit from it – this would seem an ultimate hubris.  Now, in 2018, I don’t see much change from 2012.  Perhaps there has been some due diligence going on.  The medical system is the government system in China.  There is a small private piece of the market, but it is of little consequence overall. In the vast majority of cases, it is the government hospital, government doctors, that Chinese will choose to trust.  After all – as has been the case in China for two thousand years – a private provider of a service has an incentive to cheat you.  In theory, the government provider should have no conflicted goals.

There are private market hospitals in the major cities including Hangzhou, particularly for pregnant women.  We looked at a couple of them.  They are close approximations to what I would expect from a pregnant women’s hospital in the US.  I was impressed.  Qing was more circumspect.  The hospitals are designed to serve 22-year old Chinese girls, who can pop babies out like candy.  Qing was almost twice as old, and the private hospitals were really not set up for medical complications, which old moms might have.  We chose the state-owned Hangzhou Pregnant Women’s Hospital, a couple of blocks from Xihu. This is a highly recommended hospital with the top rating of hospitals in China.  I used several connections to get us a VIP room at the hospital, which usually required not only guanxi but a reservation four or five months in advance.  Calls were made, and our reservation was confirmed.  Pretty much like the Hyatt, which was also just a couple of blocks away.  The story begins –

We are at D-Day minus 1. After class, we leave for the hospital, with suitcases and bags full of household goods. The plan is to stay for a week, since the delivery is to be by Caesarian.  Qing is pretty small, and she is not 19 years old, and natural birth might be tougher. The idea has been to do the birth by Caesarian since the beginning of seeing doctors, about 9 months ago.

We got to the hospital about 1:30 in the afternoon, Qing and her sister and I, and we went to the 8th floor of building 2 to see the doctor. This is the doctor Qing has seen for the last few months, and she is supposed to do the delivery tomorrow afternoon, after lunch. Say, about 2:00. This was just a quick hello, look-at-the-stomach visit, about ten minutes tops. Then, off to pay the money. Everything is paid in advance. Makes it easier for the hospital if you have complaints or a crisis, and want to take issue with the service. They already have – not only your money, but your bank account information. No credit cards – no intermediary to assist in a dispute, a la American Express.  Cash, or direct withdrawl. The hospital can presumably drain your bank account, if they want. Not sure they need the nicety of a signature on a receipt, and, as I tell my negotiation class, so you have a receipt.  If you don’t agree with the result, or have a problem, what to do, now?  In libertarian China, cash is king.  And people have to take personal responsibility for their health care, in ways that Americans could not imagine.

At about 3:00, we were in the room and registered. Not bad, considering all the prior SBB (stupid beyond belief) events of the previous months. This was the process.

Signing in took only about ten minutes, as well. Much faster when people have to take personal responsibility for their medical care. I mean, there was no worry about insurance. This is due to the manner in which health insurance works in China. Instead of the insurance company standing between you and the medical establishment, the insurer simply reimburses you for your prior expenses. You collect all the bills, invoices, statements you have accumulated over the last 9 months, and submit them as a package to the insurer.

The insurer then decides how much they want to pay, and after some time, they send you money. There does not seem to be any knowledge anywhere about what insurers will pay for and not pay for – certainly, no agent standing between you and the insurer. There does seem to be general knowledge that pregnancy is not considered an insurable event – I mean, personal responsibility again – if you are pregnant, that is your doing. You probably had a hand in the deal, or were at least in some way complicit, so this puts you in a moral hazard position. You could have not gotten pregnant, had you just been careful. How can we insure against such irresponsible behavior?

So the insurance company will pay for some things, and pay for some parts of pregnancy and childbirth at a lower rate. Apparently, you don’t know what they will cover or not, and there is no negotiation involved. As with many things in China, you simply take what you get. If you want to know why something did not get paid, you confront the System. Don’t forget the end-of-discussion put-off – ‘No why.”

The pay-in-advance health insurance system does have additional benefits for the insurance companies. Can you keep straight all the invoices and bills for medicine, and doctors, and tests, and hospital visits, for a major surgery? Think you might misplace one or two in the battlefield chaos that characterizes walking around the hospital in China? You are standing in line, to pay, to get a number, to see the doctor, to get a test, running from floor to floor without clear directions as to which office to go into, all the while keeping your medical records and receipts and schedules in a clear plastic pocket file.  You know, the kind of files that you might put receipts in, to add up at the end of the year to do income taxes. That is the preferred means of storing medical records here.  All this running around is done while pregnant, and fighting through the hordes of people all trying to do the same deciphering of the System.  God forbid you should have to go to the bathroom somewhere in the process, and lose your place in line.  You are constantly taking pieces of paper out of the pocket file, putting paper in, showing to this clerk or nurse or that one, making sure the paper is stamped, and stamped properly.  Think you might misplace a receipt?

If you do need a duplicate bill for some piece of the service, are you really going to go stand in line for another couple of hours at the hospital to do that? Take a day off from work to run through the labyrinth? Maybe better to just eat some bitterness, as is the age-old phrase in China.

The insurance companies make out ok in another respect. The sheer volume of crowds, and the delay, and the personal care 
of medical records (with attendant possibility of loss, or false recording, or missing information) mean that many illnesses that are covered by insurance probably do not get treated, or they get treated to a very low level of quality. The government claims that 95% of Chinese have health insurance.  That is no doubt true, as true as any statement in extremity can be.

Cost savings from lost records, geographic isolation, and extremely limited coverage are passed on to the government and the insurance companies.  And really, what good is an insurance system that can’t make money?  In China, we should always be thinking of the greater good – that of the System.  George Orwell understood very well.

Take heart attacks, or cancer. No doubt whatsoever that
 the crowds and delay and general incompetence – not to mention lack of availability and coverage –  kill a lot of
 people before they would die in some other parts of the world.  We have a new hospital not ten minutes driving from our apartment.  But in the difficult world of traffic and non-yielding of drivers to emergency vehicles, that ten minute trip could easily expand to an hour or more.
  And don’t forget that the largest businesses in China, including
 the health insurance companies, are state owned. So the
 government and the companies have some common interests -
they have moral hazard problems, as we say in micro class. 
The State designs the health care system. The insurance
 companies live in it. But both have an interest in keeping medical care costs down. I am not trying to be too flip about this – a little, but not too much – the organizational
 design reminds me of the joke about hitting a pedestrian
 with your car – better to kill him, than injure him. Back up and roll over him again, if you need to. The State designs 
the system for delay, and inattention, and grinding, from building design to scheduling of visits to provision of care to reimbursement for expenses. The State 
helps the insurance companies by keeping too many people 
from getting care that is too good. Good care would mean more costs for the insurance companies. Lower profits mean lower GDP growth.  It is really the case that some Chinese just choose not to go to the hospital rather than enter the System.

In the US, we have had the discussions about providing health care for most Americans. The concept is that providing decent preventive care, and decent routine care, will prevent much more costly emergency care when there is a crisis. But this is different systemic thinking than in China.  The health care system does not work well for many people in either place; but I venture to say that the system works better for the majority of people in the US, even at ruinous costs in premiums, than it does in China, where premium costs are less but service and availability and coverage and information are much less.

Keep in mind that we are living in the capital of one of the three or four wealthiest provinces in China. We are in the Zhejiang Province Pregnant Women’s Hospital, the hospital generally acknowledged here as the best place to be.

So other hospitals, in other places, are not as good, even in Hangzhou. And there are other cities in Zhejiang Province. And there are other cities in China. And there is the rural countryside, where some medical care is now provided but sort of at a “first-aid” level of service. There is a lot of faith in folklore and tales and medicinal herbs and Chinese culture, though. Easier, faster, less expensive, and for many things, just might work.

In the US, the insurance companies want the government to provide coverage, or demand that people buy it. The companies will make out like bandits – more customers, more profits. But in China, my guess is that there is no such 
push from insurance companies to provide more health coverage for rural people, or to improve the level of care for urban people. More coverage for rural people just means that the government has to pay more to the insurance companies for the care. A higher level of care would mean that some people would live longer, and require more services. And improving the quality of care would just cost more money. Where is the benefit? How does providing more care improve GDP?

You begin to understand how big companies in China can be
 so profitable. I mean, there are plenty of other reasons -
sweetheart contracts, and soft budget constraints on state-owned companies, and cooking the books, if needed. But
 costs of providing services, whatever the business, are low – 
labor costs are typically 70% or so of business costs, even in the US.  In China, land costs are a much greater portion of overall costs than in the US – either acquisition costs or rental costs.  And labor is cheap in China, even with rising salaries and some overstaffed organizations. And, in general, the level of service provided, in relation to the costs, is poor.  For many things, the costs to the customer in China are higher than in the US – cars, apartments, clothes, electronics, household appliances, furniture. There is a large 
enough middle class to pay for the extra costs. But there is a huge part of the population that is left out of the market, and no short term way to bring them into the market. And, even 
if a couple of hundred million more people can be brought into
 the system, the quality of what is purchased is often quite poor.
 You remember me bringing suitcases full of cosmetics, vitamins, baby formula, and electronics to China on my trips back from Chicago.
 All the same goods are available in China, same packaging, quite possibly made in China, but people in China trust what is made in
 the US, or at least imported into the US from China and then sent back to China, more than the same stuff made in China and distributed in China.
 The lack of enforcement of quality controls, inability to control the supply chain, lack of enforcement of intellectual property laws, and the lax treatment of copying, means that people in China have no
 confidence that the Louis Vuitton bag in the LV store in China is really an LV bag – or that the drugs purchased in the Watson’s, or the hospital pharmacy, are real.  And they have no confidence that the 
Elizabeth Arden face cream, or the Robitussen cough medicine,
 same box as in the US, same labels, is not made in some
 garage using waste products for raw materials. So, the same model Mercedes Benz car that is made in Germany costs much more than the Mercedes Benz car made in China, and the difference is not only in import fees and shipping.

So, suffice it to say that the level of service in the hospital reflects the design of the culture. The System is designed for mystery and conservation of power.  The System is designed not to provide information, and not to make personal decision-making easy. When people cannot get the information they need to make decisions, they resort to whatever might seem to give them a hint as to quality – rumor, online evaluations (even if those, too, are fake), smell, trust obtained through personal guanxi.  The result is a herd instinct – quality detected in one arena leads to great market demand, and distortion of prices.  There is a saying about quality in China – “People don’t know.  Money knows.” Meaning that price is a strong indicator of quality.  That might be more true in China than in the US, with its regulation and inspections and ability to sue and free media.

The room in the hospital is actually sort of ok. We are paying an extra 40,000 yuan for one of the VIP rooms on one of the upper floors.  The VIP rooms separate the officers, as it were, from the enlisted men. The lower floors have the enlisted women’s delivery and recovery rooms. Four or five women to a room, beds lined up like in an episode of MASH, although with the beds closer together and probably not quite as sanitary as the MASH units actually were.

We have one of the officer’s quarters rooms. Bright, lots of recessed lights, flat screen tv, microwave. As befits the Chinese interpretation of hospital room as hotel room, there is a mini-fridge, a bathroom with one of those Japanese electronic toilets that do all those things that we don’t really know about, and you are afraid to push any buttons because you don’t know what might squirt you and with what and where. And lots and lots of closet space. More than in our apartment. Shelves, places to store boxes, like people are moving in for a week. Which, actually, I guess, they are. There is a couch that folds into a bed, for the spouse or relative to sleep on. There is one not so nice chair, and a small dresser. The afternoon light is good, and we are high up enough to get only background traffic noise, which to me is ok – some awareness of what is going on outside, while our own intense attention and activity is focused inside.

It turns out that we needed the closet and shelf space.  I did not understand why we left our apartment in Hangzhou with so much … stuff – towels and bed linens and plastic bowls.  Turns out that we have rented a hotel room, although a fairly low class hotel at that.  Customers bring their own bed linens, towels, bowels for washing and cleaning.  The hospital provides very nearly nothing except a bed with one set of sheets and blankets.

It is now 4:15 in the afternoon. Qing is off doing other tests, ultrasound, blood tests. When she returned, I thought that we could order food from the hospital for lunch, or dinner.  Wrong again.  Our hotel room is not American plan. If you want food, you can buy it from the hospital restaurant (in the VIP rooms, you order from a menu. In the enlisted men’s – or women’s – rooms, your choice is the shitang, the dining hall, with military grade dining).  In the majority of cases, the patient’s family brings food in from outside and mix and heat up ingredients in the room.  It is up to the family to make sure the patient gets a proper diet, even after an operation –  again, taking personal responsibility for health care.  And again, this is the VIP room.

Events for tomorrow are shaping up as follows – morning, nothing. Watch tv. After lunch, about 1:30, the main events begin. Operation will take about 90 minutes, including recovery time, and they don’t give Qing any relaxant, or pill to get her a bit groggy, much before the operation. At this point, I am expecting to have some details to report by about 3:00 our time.

Signing off for now. More when events warrant.

Update. At 2:00 AM, Qing’s water broke. She called the nurse, using the call button. Nurse comes, surveys the situation. Does nothing. For those of you who have not yet figured this out, China can be a libertarian’s wet dream. It is personal responsibility all the way. As I mentioned before, the hospital room is really more like renting a hotel room. There is a bed, and some closets. But no towels, cups, glasses. One bottle of nearly empty hand soap. As with a hotel room, there is a shower with small bottles of liquid soap, shampoo, some 
other kind of lotion. But no washcloths or towels. There is one box of tissues, and a reasonably full container of toilet
paper, but those items are not replenished when empty. Bring your own. What was in the room when we walked in was left over by the previous tenant – and not taken away by the cleaning staff.  Personal responsibility dictates that you bring your own towels, washcloths, tissues, toilet paper. The hospital provides a room, and a once-a-day change of sheets.  If the sheets get soiled, or wet – as in, a pregnant woman’s water breaking – well, too bad. You should have thought of that when you moved in. Wait until tomorrow to change the sheets.

So, back to water breaking –

There are people here who walk around with white uniforms, and are called “nurses,” but I doubt their competence. They refuse to answer any but the simplest questions, and they refuse to do any work. So the “nurse” who comes in to survey the damage from the water breaking does so, I think, only so she can file a report saying that the water broke. All the clean up, all the replacement of sheets, is done by anyone else in the room other than the people who are paid to work at the hospital. Same thing for assistance in bed pan use. In the hospital in China, you make provisions for your own bed pan changes. Personal responsibility. When the water breaks, the only reaction of the nursing and doctor staff is to ask us – us – whether we want to wait for the regular doctor, at about 2:00 PM as originally scheduled, do the operation now, at 2:00 AM, or try to do natural child birth.

The question is presented as you would ask someone if you want fries with that, and the answer is expected to be about as thoughtful. No questions allowed, other than the most simplistic. No information on what others do, no consideration of age or particular situation, no consideration of progress in having contractions. Personal responsibility. You decide about your medical care. When you decide, the hospital will deliver the goods, as it were. But you cannot ask about consequences, you cannot get information on common practice, you cannot ask what someone with – you know, some medical training – would do in a similar circumstance. For us, the demand for a decision is a false choice, since there is no harm in waiting at least until the morning, and that is what I suggest to Qing. She agrees. So we wait.

There are bed mats, of a sort, that one can put under a person who is draining anything, to absorb the liquids and sort of prevent the patient from having to lie in his or her own excretions. You can buy them in the stores in the US, for use at home. You change them as needed.

The retail market for such mats is big in China, because people have to bring their own to the hospital. And, you know, if you bring it, you should install it. So the nursing staff will not change the mats. You can throw the used ones in the corner, and maybe tomorrow someone will come by to pick it up. This is the VIP level of service in one of the most sophisticated hospitals in Zhejiang Province. God help you if have only one person to assist you in the hospital. You need two people to lift up the patient and remove the used mat and put the clean one underneath.

Which brings up a larger question – what happens to the person who does not have two or three or four family members who do not have to work, who can take days off at a time to provide round the clock care to a relative in the hospital?  You can rent assistance – farm women are available outside the hospital to come in and be surrogate family for a few hours or a few days.  You can imagine their level of care in changing sheets, bedpans, and cleaning up.  My guess is that people who need to rent such help have a high rate of infections or other complications. But no need to worry about the hospital – personal responsibility. No worry about malpractice lawsuits.

The suggestion of trying natural child birth is an interesting proposal. In the prior 9 months, no one thought that natural child birth would be a good idea for Qing, given her physical size and age. Now, you know, neither the doctors nor the nurses nor the hospital generally have any information about Qing whatsoever. Patients provide their own medical history and “chart” information. The hospital has approximately the information that a hotel would have about its customers.  So I suppose one could forgive a 14 year-old candy striper volunteer for making the natural child birth suggestion to Qing and me. But that is not supposed to be the sort of person we are dealing with. We are supposed to be talking to a “nurse” – one with surgical or at least obstetric experience – we are on the VIP floor of the Pregnant Women’s Hospital. So the only justification I can see for offering the natural child birth option is that the hospital would make more money. Now it is true, with natural child birth, the delivery cost is less, and a woman only stays in the hospital for 3 days instead of 7.  But as is often the case, I think, Chinese are playing a different game than we would play in the US. A personal responsibility game. If you begin the natural child birth, and then have to switch to the Caesarian due to complications, then the hospital charges you for both procedures. I knew that. Trusting soul that I am, I asked that question a few days before, when we did the tour of the VIP floor. Beat them at their own game, that time, I did. So the suggestion to try natural child birth is actually to request an upgrade in service, albeit one that might end up costing us double. But, you say, what about the difference in the money received for 3 days hotel room rental instead of 7 days? Doesn’t that still provide a loss for the hospital, if you opt for the natural over Caesarian? Not necessarily. You have to consider turnover. If the hospital can process two births in the time once reserved for one, the increase in payments to the hospital is not so marginal. So – the hospital proposal is, try the natural child birth, which, if you find you cannot do it, we charge you for two births; and if you do the natural child birth, and it works, we can squeeze another customer into the schedule, with another birth and the attendant extra costs.

There are other complications. Our doctor, who works every day at the hospital, and only sees patients with a fair amount of guanxi, and probably sends most of her customers to the VIP floors, does not seem to have the same status on the VIP floors as the doctors assigned to the VIP floors.  Perhaps this is because our regular doctor gets different kickbacks than the full time doctors on staff – I really don’t know, but that is a fair guess. The regular doctors assigned to the VIP floor get an end of the year bonus if they take business away from the other doctors, or something. Only speculation on my part, but I am confident that such a system could be possible. So the nurses on the floor are sort of pushing us in the direction of not waiting for our “regular” doctor to do the operation. The nurses probably get a cut of the doctor’s bonus.

Qing wanted to wait, but the contractions started coming pretty often, and by 7:00 AM, we are down to four minutes, lasting about two minutes.
We decide to do the operation now. The hospital staff concurred with our excellent decision – get Qing in and out early, and perhaps the processing of regularly scheduled Caesarian births could still be maintained.  A woman comes by with a bed, to transfer Qing to the operating room. The woman does nothing. We (Qing’s sisters and I) transfer Qing to the bed. The hospital woman stands there. We put the railings up on the sides of the bed, and we wheel the bed down the hall. The woman does provide directions, though. I have to give her credit for that. Real personal responsibility would have demanded that we stop and ask for directions to the operating room, a couple of floors away.

Contempt is the word that comes to mind – my feelings about the hospital and staff. I know they are subject as well to the System grinding down process, but I cannot feel sympathy for their situation, since I detect none in them for us. I asked, or Qing asked, a “nurse” about the frequency of contractions, and strength, and duration. All are indicative of progress in birth process. I know that to ask such questions is high impertinence, but that is just who I am. The “nurse” was able to tell us that contractions five minutes apart were closer than contractions that were 10 minutes apart. She did volunteer, though, that stronger contractions were more significant than milder ones. She must have taken the extra credit classes in nursing school.

When we get to the operating room, all is ready – if they can start by 7:15, they can finish by 9:00 when the regularly scheduled customers start to arrive. Maintain the schedule. The doctors give Qing a sedative and anesthetic.  They start to cut on her stomach before the anesthetic fully kicks in, but that is ok.  The doctors remain on schedule.

Ben is born about 8:45 AM, November 2, 2012.  He is fine, and Qing is as fine as she can be, given what she has gone through.  Done by 9:00.  Phew.  Got in and out just in time.

At one point, about 1:30 in the afternoon of November 2, when Qing and the baby are trying to sleep after a trying morning, three different “nurses” came into the room in a span of about 25 minutes. This is what they did – one turned on the lights and woke everyone to check Qing’s blood pressure – which is already being constantly monitored on a screen, and certainly does not require turning on any lights; second one comes in to wake up Qing to take her temperature, which really doesn’t require waking her; third one comes in to take the baby’s temperature, waking him up in the process. My guess is that in the US, the over-regulated, too-expensive US, one nurse would be able to handle all three of those difficult tasks. She might come in just as you and the baby were trying to sleep, and turn on the light, but it would only happen once. By the way, this sort of invasion happened again, later in the afternoon, when again all of us were trying to get some sleep.

At about 4:00 in the afternoon, the “nurse” who is supposed to show us all how to put the baby on the nipple, found that the baby had pooped, and the diaper needed to be changed.  I have already told you that “nurses” here do virtually nothing – they do not change out catheter bags, for instance – again, more taking personal responsibility for health care – but this “nurse” proceeded, probably against the training of the last 60 years of Chinese culture, to change the baby’s diaper for us, wiping off the poop from his butt.  She did, however, expect to stop after two cursory wipes, when poop was still stuck everywhere on the kid’s bottom. I had to go from spot to spot, pointing out, three times, where this (deleted) “nurse” had yet to actually clean the kid off. If the kid got diaper rash, no doubt they would blame the ignorant foreigner parent.

Not changing out catheter bags, by the way, means that the family has to bring several plastic bowls, pretty big, to the hospital.  So that is what the plastic bowls are for – to catch drainage or leakage in process.  At least one to empty out things like catheter bags, or maybe store the soiled bed mats until someone can come by and take them away. My plan is to just dump all the waste outside the door, and let someone else clean it up. I think my years in China have taught me how to be more Chinese.

Pain management does get a high level of attention in the Chinese hospital. The key goal is to keep costs down, so patients are expected to just sort of grin and bear it. It is now Saturday morning, about 24 hours after the birth. Qing has been in some pain since yesterday afternoon, at the site of insertion of some drip. She has asked for something for the pain, but the “nurse” came in, talked to her for a moment, and assured Qing that everything was ok.  She was offered some sort of temporary relief via a shot – but, personal responsibility again, we were warned that the shot would cost extra. For most people, pain should just be overcome, like a good communist soldier. For the cause.

And that is the end of it. Qing sent me home for some sleep last night. No doubt that I needed it, but I think she also sent me home to keep me from physically harming a “nurse” who tells me that pain is ok. Grin and bear it.

The thing that knocks me out is that the population goes along with this lunacy. If the “nurse” says it is ok, well, then. It is her experience that triumphs the pain of the individual. The patient is just supposed to be more stoic, more Buddhist, more Daoist, I dunno, offer it up to Jesus, or something. Grinding.

I am convinced at this point that it would have been less expensive, and more efficient, and with higher level of care, if we had just rented a regular hotel room in a hotel, and then hired a doctor and some real nurses to take care of Qing and the baby for a week. I would be willing to fly them over. There are reports of good expat hospitals in Beijing and Shanghai. But so far, not in the capital of one of the three or four richest provinces in China. After all, China is still a developing country. And for all those libertarians in the US, maybe progress in medical care in China has gone about as fur as it can go.  Like the World’s Fair in St. Louis in 1904.  With regard to personal responsibility, it is about the best of all possible worlds.  “Progress” would almost certainly mean the hospital taking on more risk.

Some liberal bleeding heart reading this in the US might want to stick up for the underdog hospital and medical system in this story. After all, it is a different culture. It is China. Chinese women’s bodies are different from those of women in America, I am told.  I don’t understand the culture. I don’t understand the wisdom of the System.  5000 years of Chinese culture. After all, 1.3 billion people got born here in the last 80 or so years.  All their moms got through the process. Why should I impose my western standards on China?

This is the point at which the cultural relativists, already in agreement with libertarians on a lot of issues, have a problem with medical science and basic personal choice. Many women in China who have the means opt to go to Hong Kong, with western medical standards, to give birth. Screw 5000 years of culture. When I am in pain, give me medicine. When my baby needs care, give it to
 her. Don’t tell me that pain or infection or inattention is God’s will, or Fate.  I am choosing not to believe Todd Aiken, the Republican congressman from Tennessee who claimed that in the case of “legitimate” rape, women’s bodies “just have a way to shut that whole thing down.”  In the cases of “legitimate” pregnancy, I don’t think women should just suck it up and bear the pain. Political scientists talk about two choices for people in a society – voice, and exit.  Express your desires, work for change, or leave. The first choice, voice, is not doing Chinese women any good just yet. So, if they can get out for pregnancy and delivery, they get out or they finagle their way to more guanxi than I have.

I have been referring to the hospital here as a dongwu yi yuan – an animal hospital. But that is really unfair, to the animal hospitals in the US. Yes, it is true that people get treated like animals, and their personal care and time mean nothing to the System. Only the processing of people matters. There are pretensions to the contrary. The floor on the VIP floor is pretty clean. The lights in the hallway are bright. There are some plants, and I can look down the hall and see a “nurse” walking, but no horde of humanity pushing to cheat their way in line or get theirs before someone else does. But as with many things in China, the cleanliness and newness are form over substance.  As in the Wizard of Oz, best to not look behind the curtain.

Enough for now.  Written on my hospital breaks, when the niece and sisters are taking charge of changing catheter bags, and washing the towels that we brought to wipe off Qing and the baby, changing diapers, and bed mats. They really are much better at all this than I am. After all, it is China. They have much more of a sense of personal responsibility.

Health Care Crisis

Some of you have read prior posts here on health care, the good, the bad, and the unbelievable.   Now comes the New York Times with a feature on the Crisis in Health Care in China, focusing on the shabby treatment of doctors and patients in the medical system.  As I noted in Hospital Rules (see the Health, Education, Welfare tag adjacent, to the right), the system optimizes for neither patients nor practitioners. 

The video in the NYT piece shows a man making home-made drugs for his mother, who has stage 3 cancer.  She has insurance, but cannot get coverage for drugs that are far too expensive to buy commercially.  If her insurance works as I think it does, she would have to buy the drugs, pay for them, and then get part reimbursement by the insurance company at some later date. 

How Capitalism Ruined China’s Health Care System  

From the NYT article –

China’s Health Care Crisis

On some mornings, Dr. Huang Dazhi, a general practitioner in Shanghai, rides his motorbike to a nursing home, where he treats about 40 patients a week. During lunchtime, he sprints back to his clinic to stock up on their medication and then heads back to the nursing home.  Afterward, he makes house calls to three or four people. On other days, he goes to his clinic, where he sees about 70 patients. At night, he doles out advice about high-blood-pressure medications and colds to his patients, who call him on his mobile phone.  For all this, Dr. Huang is paid about $1,340 a month — roughly the same he was making starting out as a specialist in internal medicine 12 years ago.

Doctors so poorly paid must find other ways to make money, and writing prescriptions is a principal means.  Doctors receive kickbacks from suppliers as a way to supplement income.  This is illegal, but without complete reform of the system, there is no way to end the practice.  The incentives are too great on all sides of the issue – suppliers, doctors, nurses, even patients.  The government has said it would crack down on the practice, but to little avail.  The government did fine GlaxoSmithKlein $500 million in 2014 for paying bribes to doctors and others.  Chinese pharma companies were noticeably absent from any prosecution in this regard.  NYT GlaxoSmithKlein fine  or if you do not have a NYT subscription, BBC GlaxoSmithKlein fine.  From my own experience in China, the system remains unchanged.  

Chinese have little respect for the medical system, and doctors are at the receiving end of patient anger.  It is common to read of doctors assaulted, even killed, by enraged patients, parents, or siblings. 

In this file photo, hospital staff walk past a security guard on duty in a hallway at the Beijing Friendship Hospital during a government supervised media tour on February 29, 2012.
In this file photo, hospital staff walk past a security guard on duty in a hallway at the Beijing Friendship Hospital during a government supervised media tour on February 29, 2012.   ED JONES—;AFP/Getty Images
 
A few more references –

http://time.com/4402311/china-attacks-doctors-medical-police-medicine-healthcare/

https://www.wfyi.org/news/articles/in-violent-hospitals-chinas-doctors-can-become-patients

https://www.nytimes.com/2016/05/19/world/asia/china-attacks-doctors-hospitals.html

But overprescribed – and overly expensive – medications, battlefield conditions of treatment, and lack of training are an affront to even middle class Chinese who see excellent care for some, and a completely ignorant system otherwise.  As I mentioned in other pieces, it is frustrating to know that better treatment exists, and you cannot have it because someone else – maybe the woman who walked in after you – has superior guanxi.  When patient outcomes are less than desired, the frustration can boil over. 

Picking out a doctor to treat you, like picking a train back to the suburbs from downtown at 5:10 –

An electronic board at the entrance of Peking Union Hospital displays the number of doctors available and their specialty.  CreditGilles Sabrié for The New York Times

My own minor experience – when we were seeking to book a room – like in a hotel – at the Pregnant Women’s Hospital in Hangzhou, we were kept waiting outside a locked door on the patient floor for more than half an hour, while events unfolded inside. I knocked on the door several times, the guard at the door saw me, and simply ignored us.  The guard controlled access, and others were let in ahead of us.  My own frustration, boiling over, was relieved when I bolted through the door as another women was let in ahead of us.  At that point, there I stood, alone inside, with my wife and sister-in-law and a bunch of agape Chinese outside.   But, fait accompli – I was inside, I was a foreigner, and the only reasonable solution was to let the rest of my party into the floor so we could – check out the VIP room, as arranged previously, the room we were paying for. 

Oh – another personal experience -when our son was born, some medicine was handed to my sister-in-law, sleeping in the room with my wife and new born son.  She was instructed to put this medicine in my son’s eyes a couple of times a day.  (Nurses don’t administer medicine).  No suggestion that something was wrong, no discussion of adding this to Ben’s post natal care.  What was the medicine for?  I was not going to have someone put stuff in my kid’s eyes without knowing what it was for.  No one – not any of the nurses, not the head nurse – had an answer.  The medicine was prescribed by my wife’s doctor for our son.  Un-huh.  I declined, and told the nurse to take it away if she couldn’t provide a reason for its application.  “Oh, no, the package is already opened.  You must take it.”  (meaning, you must pay for it.)  Again I declined.  Much discussion and phone calls followed, which I am quite sure only took place because I was a foreigner.  Finally, a resolution to the impasse.  The hospital found another new mom who did not – or could not or would not – object to application of the medicine for her baby, even from an opened box.  We were relieved of responsibility.  No doubt the hospital gave the other new mom a discount on the meds that she never authorized or was told about.   But the system persevered – the system of mystery and control – and the system emerged victorious.

Hospital Rules

Summer and Fall, 2012 

(reader note – this is a bit long, but has some details about hospital care.  Forewarned is forearmed)

A while ago, I wrote about mysteries of the parking lot market in Hangzhou. 

There are procedural mysteries everywhere in China.    Systems that are clearly not care-full of the needs of customers, but at the same time, seem not to be in the interests of the provider.   Hospital operations are another good example.   Take the Zhejiang Pregnant Women’s Hospital, one of the AAA rated hospitals in China.   Or the Hangzhou No. 1 Hospital, across the street from the Pregnant Women’s Hospital, another AAA facility.   Or, I surmise, most any hospital in China.   The systems, both physical and procedural, seem chaotic, redundant, and stupid, for every human inside the building.

It is supposed to be a sophisticated management insight that systems try to optimize.   Something.   Maybe not customer satisfaction, but maybe management benefits, or leader salaries, or bureaucratic time.   Profits.  Maybe it is hard to see what is being maximized or minimized, but by default, something must be. 

Hospital Rules has two meanings here – the procedures and requirements that any organization must impose to maintain order; and the peculiar implementation of rules in hospitals in China for which the only discernible purpose is to grind the customers into submission.   The administrative system – the Rules – uber alles. 

Source: my Experience at a Chinese Hospital  http://www.chinadaily.com.cn/opinion/2014-04/23/content_17455961_2.htm

So we think that hospitals, like any other institution, anywhere, are maximizing someone’s comfort, someone’s benefit.   Could be doctors – we think that, in the US.  Could be hospital administrators.  Or insurance companies.  Or the government.   No one thinks the system maximizes patient care.   Certainly, no one in China thinks that.   Maybe benefits accrue to no one physically at the hospital – maybe it is the government officials in charge of setting standards for hospital procedures, or  those benefitting from contractor or developer kickbacks, who are many years gone from observing the actual operation of a hospital, but nevertheless profited from designing hospital systems.

That could be.  Architects are notorious for maximizing their own interests, to the detriment of the customer or the operator.   The system in China could be maximizing the interests of some group of original hospital designers.   Flow charts and department layouts and coordination with other hospital departments.    Flow of paperwork, flow of people, flow of medicines and blood vials and cleaning supplies and band-aids.   It is no accident that hospitals are laid out as they are.   

In China, the physical design admirably reflects the lack of concern for normal procedures.  It is as if all these people showing up every day – who could’ve known?   It is not as if the hospital layout was designed in the 1920s, and modern medicine needs different size rooms and storage areas for equipment, and wall space for oxygen and air and ten other fluids, and the poor old buildings are just trying to cope.     I mean, the floor layout, and the room sizes, are entirely appropriate to the battlefield conditions one finds in the hospitals at any time of day.   In other words, the battlefield conditions are built in.  The Pregnant Women’s Hospital is really a Chinese MASH unit – maternity and standing hospital.  God forbid that pregnant women would want to sit down.

You can probably guess by this point. I do not suggest that hospital procedures are designed to maximize patient comfort or satisfaction.     But let me give you some details.   The hospital system, like many systems in China, is designed for grinding.   Grinding people, to the point at which they give up protest, or resistance, or care about quality, and settle for … whatever the system provides.     Animals will protest when you beat them, but if you beat them enough, they will work for you.    Power maintains its privileges through mystery and struggle.   Power, in the hospital system, may not be maximized, but it is conserved.  The system uses just enough mystery, just enough struggle, to retain its privileges and force the patients, and their spouses and assistants, to submit.

The Pregnant Womens’ Hospital in Hangzhou has multiple entrances.    In a place with hundreds of people going in and out at any one time, this probably makes good sense, not to funnel everyone through one set of doors.    But the physical hospital layout exhibits one of the Chinese characteristics in building that I just cannot get over, unless one considers the role of mystery in Chinese culture.

This is the penchant, everywhere, for making building exteriors indistinct and their interiors confusing.    We all like buildings that are not foursquare boxes;  but we also appreciate when a building tells us something about where to go, or how to get there, whether with signs or design.   Chinese hospitals do neither.    Mystery is a key design principal – the less you know about how a building works, the more power the building management has over you.    Not that the management really needs to exercise power over patients;  patients are already at something of a disadvantage by walking into the hospital.   But mystery, whether in design, or communication, supports power. 

At the Pregnant Women’s Hospital there are three main hospital buildings, all built at one time.   It is a hospital, so you don’t expect every floor to have the same layout, but you sort of expect some connectedness in going from building to building, especially at the first floor.

But you can’t walk from building 1 to building 2, or building 3, by any means other than by walking through an alley, crowded with moving trucks and cars and people, and then by narrow hallways full of old computers and hospital equipment lying around the corridor.   Sort of like the garbage dump inside the spacecraft in Star Wars, into which Luke and the Princess and Han get dumped, and the walls start closing in on them.  No scary underwater creatures, though.   We are not really in a movie.   Too bad.   That would make more sense.

And it is not in the design, people were not expected to walk between buildings.   They must walk between buildings to get different pieces of their own health care.      But the unclear physical layout is the beginning of the mysterious Chinese process of grinding down, by means of design.    Some more examples –

There are generally no clinics, or individual doctor offices in China.  When someone has a cold, they go to the hospital.    And even in the Pregnant Women’s hospital, with multiple entrances, everyone has to pay first, before service.   I have used hospital emergency rooms two times, and even then someone has to pay for you before you get served.    If you are dying, or bleeding profusely, or in extreme pain, make sure you have at least two people to go with you to the hospital – one to drive the car, and wait in line to park while you go inside, and one more person to stand in line to pay for you.   Bring some money, as well.   Not a lot, maybe a few yuan, but fee for service is the operating principal much of the time.   If you need help getting upstairs to see the doctor, bring another person.    (Actually, fixing these inappropriate procedures would cut down significantly on the crowded conditions – no one looking for emergency treatment would dare come to the hospital alone).

Now, about paying for service – this can get complicated.  Sometimes, you can stand in line to pay, tell the cashier what is wrong with you, and they will charge the appropriate amount and give you a receipt to get served by the doctor somewhere else in the hospital.   Ok.   But most of the time, it seems, you must have a signed note, sort of like an appointment, but not really, from the doctor before you can pay.   So – you have to go see the doctor, stand in line at the doctor’s office, to “get a number,”  as they say here, so you can pay before you go see the doctor.   I am not kidding.  This is not true for emergency procedures, but it is certainly true for most any normal procedure, including monthly trips to the gynecologist, in the Hangzhou hospitals. 

Payment is always on the first floor, generally at least one floor and half a hospital away from the office where you had to get a number from the doctor.   The patient, whatever condition they are in, if they can walk, they should physically carry the piece of paper with the number to the business office, where the payment can be made and the receipt will serve as admission to the presence of the doctor.

If you have sufficient guanxi, you can see the same doctor every scheduled pregnancy visit, every month or two weeks.   But don’t get the impression that you call, get an appointment, show up ten minutes before the appointment, wait a little long, but get in within half an hour to spend a few minutes with your personal doctor, who knows your history and has your records and will more or less patiently listen to questions and provide answers.     That would be a mistake.

First of all, no one in the hospital – not a doctor, not a nurse, not a technician, not an administrator – is reachable by cell phone, land line phone, email, text, twitter, or a sense of general human compassion.    Phone numbers don’t exist or if they do, calls go unanswered.    It is not possible to make an appointment for any service, whatsoever.   When you want service, come to the hospital, and get in line.   Face-to-face is the only form of contact.   I would guess there is no patient advocate in Chinese hospitals.

Doctors are in short supply, and doctors don’t get to choose their patients, in any real sense.   They have some control over how many patients they can take on, but the nature of guanxi means that a friend of a friend can always sort of impose on a doctor to take one more patient, and for the doctor to say no would mean loss of face for the person making the request, which one tries to avoid.   So, doctors end up with far more patients than any medical standards off the battlefield would allow.   But every patient is in the doctor’s office because of guanxi from somewhere.

The doctor gets into the office at about 8:30.   Women who have previously seen that doctor, and are in some minor sense, her patients –  have been lined up outside the office since about 6:30 or 7:00, waiting to get into the office to “get a number.” 

When the assistant open the door, you can imagine the rush.   It would be comedy, if everyone weren’t so serious.  It would be sad, if this were a Civil War battlefield hospital, with men begging for care.    Here, it is just outrageous and stupid.   When the door opens, the twenty or thirty women waiting rush the door, and ten or fifteen make it inside the door.   The losers wait outside the doctor’s office door, until someone walk out.  The doctor is seated at a small desk, and the pregnant women, in various stages, are thrusting  their medical records from three sides of the desk at the doctor.   When the doctor take the medical records, the patient gets a number, which sets her place in line to – come back and see the doctor.   Not a joke.    When the doctor gives you a piece of paper with a number on it, you are IN.    By this point, the winners feel pretty special.    But that is how the grinding process works.

The wait begins.   No one is going to see the doctor for half an hour or an hour, because the doctor is sitting at the desk handing out numbers, being on the phone, looking up information on the computer, answering urgently shouted requests from the horde.

 Our particular doctor only has office hours one-half day a week, in the morning.   If you can’t get a number for that day, you can come back next week or do something else, unspecified.    But the something else does not include seeing a doctor in the next office.   You did not develop the guanxi to see that guy.

For some people though, not getting a number from the doctor is no impediment to seeing the doctor.   In our case, yesterday, the doctor gave out 28 numbers to see 28 patients between about 9:00 AM and about 12:30, when she would leave.    The   hospital itself gives out the first few numbers to see the doctor, presumably for the people who get to the hospital at 6:00 AM and before the doctor herself gets there.   The number of numbers given out by the hospital varies, but sometimes the hospital gives out numbers 1 to 10.   The doctor herself, on our last visit, gave out numbers from 16 to 33, for a total of 10 plus 18, or 28 patients.  

But some women walked in with numbers, and their names in the computer, for numbers 11 through 15, that the doctor did not give out.    She was a little pissed about the imposition, but this is extra special guanxi at work.   Not only do these five women have a number that the doctor did not give out, their names are already in the computer for the doctor to see.   She could refuse to see these patients, but even doctors have issues of guanxi to deal with, for promotions and more money and other mundane work benefits.   So, 33 patients in about 3 and one-half hours, or about 10 per hour.    Pregnant women who, in a normal world, should have questions, and fairly intricate questions at that, requiring thoughtful answers.   Not to mention saying hello, and goodbye, and measuring the circumference of the stomach, and looking at records of blood tests and ultrasounds and other tests that might have been done in the time since the previous visit.   And, constructing a story that makes sense about the medical history of the patient, to provide more tailored advice.    For the sake of patient care, one hopes that the doctor never has to go to the bathroom, or have an emergency.   In that case, everyone would just have to come back next week.

Actually, it is good that you have to wait.  While waiting, you can go pay for the visit, because you can’t come back and see the doctor without the paid receipt.   Or you can go weigh yourself, get blood pressure taken, or get a blood test.   Or a nap.    Befitting the battlefield conditions, there are people sleeping everywhere, propped up against walls and chairs, women sprawled sideways on chairs trying to get some rest, since they got up at 4:00 AM to take buses for two hours to get there by 6:00 AM, to get in line for an appointment at 11:45 or 2:30.

One needs to get the weight and blood pressure and temperature taken care of, on one’s own, in the interim waiting time to see the doctor, unless one wants to make the hospital visit into an all day affair.    Any tests, or visits, that are not completed by 12:00 cannot be done until 1:30 PM or after.   Why?     Because the entire damn hospital closes down for 90 minutes, at 12:00, for lunch.    The hospital closes down, like maybe a restaurant that closes for a couple of hours between the end of lunch and the start of dinner.    The place that was teeming with humanity at 11:55 is like a ghost town at 12:15.   At 1:25, it will be teeming, again.    Of course, anyone in line at 12:00 when the doors slam shut can reserve their place in line at 1:30.    Right.   No.    Even the line to pay, to give the hospital money, closes down.   Now that is efficiency.

The line to pay for the visit is usually not too long, maybe five or ten or fifteen people in front of you, and it moves reasonably quickly.   Maybe wait in line five or ten minutes, or a little longer.   But there can be complications.

One time, the doctor wrote down the wrong id number for the procedure we were to get – I dunno, maybe she wrote down a number for “amputate both legs,” instead of “regular office visit.”

Not sure.   But the cashier, ever precise, caught the mistake.   The fee written down by the doctor was 5 yuan short.  The hospital would have lost 5 yuan in that event, not to mention maybe Qing’s loss of legs.    I graciously offered to pay the 5 yuan right then, change the procedure order number right there at the cashier, but there is no getting around the procedural maximization in the hospital.  

Maybe you can guess.   We had to go back up to see the doctor, to make the doctor correct her serious error.    We rejoined the pleading, bleating mob in front of the doctor’s desk, and in only about 15 minutes we had made the doctor correct the id number for the procedure.   No doubt, surrounded as she was by medical records and pleading women, she felt severely chastised by the downstairs cashier for making such an egregious error.   No doubt the doctor will never make that mistake again.    Cost to us in time, standing in line the first time, arguing with the moron cashier, going back upstairs to get the id number corrected, waiting to see the doctor again, going back downstairs to pay again, about 45 minutes.

You remember Steve Martin as the weatherman in Los Angeles, in LA Stories.  His life was without care, the weather was always perfect, and he was … bored.  Bored Beyond Belief, is what he wrote on his window pane – BBB.  I am coining a new term, SBB, for procedural … complexity … in China.   Stupid Beyond Belief.    This fee snafu is a relatively minor example of an SBB moment.    We can call it SBB – minor.

After getting the procedure number corrected, we went back downstairs, stood in line, paid 25 yuan, instead of 20 – about $0.50 difference – and went off to get the blood test.

It is not so easy to find aspirin in china.   For some reason, aspirin seems to be  one of those western things that don’t fit with Chinese culture.  I don’t know why – there is certainly mystery about how it works.   American pop aspirin like … well, aspirin.  Chinese don’t.   But blood tests are a different story.

Chinese do blood tests for … everything.   If you come to the hospital for a cold, you get a blood test.   If you complain of feeling badly, you get a blood test.   I am pretty sure that if you complained that you did not have enough blood, the hospital would ….  

Pregnant women get frequent blood tests.   I am not medically savvy to know what they are testing for, so continuously, but the process is one of the scariest things I have seen in China.   Regardless of the hospital, the procedure seems the same.    Call it another SBB – minor, unless by mistake it becomes an SBB – major.

The blood test stations are designed to maximize throughput.    There are ten to twenty service stations, behind a long window, at which technicians, not doctors or nurses, take blood test after blood test after blood test.   There is room to insert your arm beneath the thick glass wall separating you from the technician.  Sort of like transactions in a currency exchange in a dangerous neighborhood, or the takeout fried chicken place at 75th and Yates on the south side of Chicago.  Just enough room to insert your arm for the withdrawl, which takes all of about ten seconds.  The Hangzhou No.1 hospital across the street has a line system – get in line at one of the stations, wait for your test.    Waiting time in line, ten to 30 minutes.   Very democratic, though.   Everyone gets in line.   If you have a cold, and are coughing badly, get in line behind the pregnant woman lying on a hospital bed, who is behind the crying baby who looks about to explode or the guy bleeding rather a lot from a head wound.    No special treatment in the blood test line.

The Pregnant Women’s Hospital is much more sophisticated.   No need to stand in line.  You can get a number from a machine, like the old “take a number”  in the delicatessen.   There are chairs in the blood test room, probably 50.   There are, of course, a couple of hundred women waiting for blood tests at any one time, so the chairs are guarded like money.   The result is that instead of standing in line, women are standing – not in line, but sort of milling around.    More sophisticated.   Feels less … socialist.  First come, first served.  Logistics people call it a FIFO inventory system – first in, first out.  All stored inventory is the same.  No special treatment, regardless.

Since some of the blood tests are needed, immediately, there is great pressure to get the test done.   The technicians swab a little alcohol, plunge in the needle, remove what they need based on the paper given to them by the patient, stick on a label, wipe off the counter, and process the next victim.

There are hundreds of blood test samples being routed to testing every hour, with a fair amount of human handling in between.    No chance for error here, right?   No one puts the wrong label on a tube, or reads the wrong instructions for the test, or types the wrong results in the computer?    It is China, you know, where everyone is very precise, down to the 5 yuan.    I am pretty sure that the official medical statistics, at least, do not mention any missteps in the blood test confusion.

There is another room, to get weighed.   Now this is not a precision “test,” even in the US.   The doctor does not really need to do the weighing, and in China, the doctor does not.   You do this, yourself, along with blood pressure test and temperature taking.   You can write down the results, or remember them.   The doctor will take your word for it.   After all, you are the patient, and you should take some responsibility for your health care. 

The temperature taking is easy.   You don’t need to worry about cleanliness of thermometers or ear probes.   The hospital doesn’t have any.   You bring your own thermometer.   If it is dirty, that is your problem.   Personal responsibility.

I am not sure how to game the temperature system – if I needed my temperature taken, not sure if I would want to estimate high or low.   After all, the temperature is measured in Celcius, not Fahrenheit, with only 100 gradations between freezing and boiling of water, instead of 212.   That means that a difference of 1 degree does mean more here than it does in the US.   Do I want to tell the doctor my temperature is 37 degrees or 38 degrees on the relatively unclear thermometer?   That one degree has meaning here.    It is the difference between 98.6 and 100.7.   My answer hinges on whether I think it is better to go home untreated or stay and be treated at the hospital.    Which would be better for my health?   Personal responsibility, again.

Perhaps everyone’s fondest memories of pregnancy are getting the ultrasound.   It is a time for a minor amount of personal attention, and you get to see what it is that is making all the fuss and the kicking, and start developing a connection.   A little personal time – mom, dad, baby.

As in the US, the ultrasound exam is done in a little room, with the technician but only with the mom.   The exam is five to ten minutes, maybe a bit less than in the US, but ok.   The process is really special, and memorable for every pregnant mom.   This is what the process is like.

The ultrasound testing office opens about 8:30.    As you recall, for the blood tests, everyone gets a “take a number”  ticket from a machine, and comes back when the big display shows that their number is coming up.  That is for blood tests.

It would be possible to do that for the ultrasounds, but that must be too simple an idea.   There is something more complicated going on that I must not be able to see with my western eyes.

So pregnant women, and their moms or husbands, start lining up about 6:00 in the morning to “get a number”  from the woman behind the desk in the ultrasound office.    By 8:30 there are – every day – two hundred or so women, each with their two or three attendants, in line around the entire mezzanine second floor.   We might have been waiting to go in for our interview on Ellis Island.  People propped against walls, lying down, carrying bags of lunch and maybe blankets and ubiquitous water bottles.  Three, six, nine months pregnant. Again, there are a few chairs, but …  This is the office designed to do ultrasounds.  With – presumably – some consideration of demand in mind.

Understand, the pregnant women are not in line to get an ultrasound.   They are in line to get a number that schedules the ultrasound.    As with every other department, the ultrasound office closes for lunch.    Some people who arrive late to stand in line – 7:30, say, an hour before the office opens – get a number for the afternoon, maybe 3:30.   There are only so many ultrasounds that can be done in one day.  There are no appointments.  People standing too far back in line do not get a number, after standing in line for an hour or so, maybe traveling a long way by bus to get here.   They don’t get a number for tomorrow.   They come back, and stand in line tomorrow.    This does great things for efficiency, particularly if the husband steals a day off from work to make the trip with his wife.

If you get a number for 3:30 in the afternoon, then, you count your lucky stars.    You can now relax for six hours or so, until your ultrasound number comes up.    This is such a special time for all moms.   More grinding.

What is being optimized?  Cannot tell.  But the hospital designers certainly had ultrasounds in mind at the time of design.  The hospital is not that old.  The first principles of design are to consider end users in design – how many bathrooms, how many elevators of what size, what size offices for how many doctors … maybe even how many pregnant women might be standing in line to get a number at 6:00 AM.  This is just supply and demand for architects.  Chinese design, in every hospital I have been to, and that is about eight, fails miserably in consideration of demand. 

I probably don’t need to tell you that the ultrasound, rather than the sort of quiet personal time with your baby-to-be-born that we know in the west, is a chaotic mess of a  time.    No doctor and mom looking at the head, and heart, and fingers.   No warm exchange of hopes for the future and love for the child to be born.     Processing people through the system is the goal.   People do not matter.  The System matters.

A key difference with the west, certainly the US, is that husbands are not allowed in the ultrasound room.   Mystery must be maintained. Husbands are not allowed due to  the Chinese one-child policy.    As you know, China has had a one-child policy, in variations, since before 1980.    The desire for a male child has led to millions of abortions of female fetuses.    To combat that, hospitals and their workers are instructed to not reveal the sex of a fetus.   A female might be aborted, particularly if the father learns that the fruit of his sperm is female.    Having the husband in the ultrasound room, able to look at the ultrasound screen, might be able to see the tell-tale signs of a male – or not.    In any case, families are usually not able to plan for a boy, or a girl, by buying clothes and toys and other things in advance.    Mystery is preserved, until the time that the State releases its control of information.

You might get the idea that in the mass of confusion in any hallway of the hospital – women in a line completely around the mezzanine floor for ultrasounds, and to see the doctor, and get blood tests, and  running (as it were) up and down the escalator to pay fees and correct mistakes, and go to the bathroom, and weigh themselves, and try to get something to eat after the blood test, and sleeping, and women about to give birth, and women having just given birth being wheeled through the traffic – in this chaos – that the hospital might be tempted to skimp on cleaning.     That would be wrong, sort of.

Cleaning, or at least the physical manifestations of cleaning, are going on all the time.   Cleaning ladies are sweeping people out of their way with mops and brooms, and moving cleaning buckets through the hallways.   This work could be done at lunch, when everyone else disappears, or in the evening,  but I think that would not convey the sense of cleaning that is key.   It is the appearance that is important, not the result.   And it contributes to the sense of chaos, and urgency, which is key to the grinding.   How can we pay attention to you, when we have all This going on around us?  Battlefield conditions.

When we got the amniocentesis test – which was strongly discouraged by the doctor –  Qing was asked to lie on a small hospital bed for about half an hour before going home.  During that time, a nurse came by to take blood pressure, and do a minor ultrasound, and everything was kept clean and sanitary throughout the procedure.   Except that right adjacent to the nurse doing our ultrasound was a cleaning lady, with a rag that looked like one of my old shirts, wiping down all the surfaces on the table where the instruments were.   The cleaning lady did not spit on the floor, or blow her nose into the rag, but I doubt that would have worsened the sanitary conditions.    But when mystery is key, and power is maintained, then form over substance becomes a virtue.    Like Fernando Lama, a la Billy Crystal, it is more important to look good than to feel good.

I think military people will say that even in battlefield conditions, it is possible to get excellent care in battlefield hospitals.   Doctors answer questions, as best they can.   No doubt they try to give the wounded some hope for recovery, as seems reasonable. 

But one of the most surprising things about medical care in China is the honesty of doctors.  This is translated as their willingness to say, in response to the simplest question about diagnosis, or prognosis,  “I don’t know.”    In the US, occasional use of this phrase might be interpreted as thoughtful and careful.    Pretty regular use would be interpreted as stupid.   But one hears that phrase over and over again, from doctors in China.   I prefer to think that the doctors here are not stupid, so I am rooting for honesty.    Maybe not well trained, maybe lazy, maybe just extraordinarily careful with what they say, but not stupid.    “I don’t know” is the answer to give in China when you want to cut off further discussion.   To ask a follow up question, like, for example, “Why the hell don’t you know?”  would be impertinent.     The cut-off-discussion answer to, “Why”  is often the curt and dismissive,  “No why.”

So, after one of our blood tests, the doctor saw that one of the blood sugar levels was high.   The doctor told Qing that she had pregnancy-related diabetes.  This can be a pretty serious matter, health for mother and baby.   The doctor prescribed a series of blood tests, three per day for three days, and all to be done two hours after eating, so roughly 11:00 in the morning,  3:00 in the afternoon, and about 9:00 at night.   Go to the hospital three times a day.  Pain in the ass.

Qing had had blood tests before.   No blood sugar problems were noted.   She had eaten before this blood test, which was ok in this case, but had a lot of stress in getting to the hospital on buses and waiting in line (I was in Chicago at the time).    The doctor did not have time, I suppose, to consider those factors.   So, a series of blood tests occupying the whole day for three days, plus the worry that goes along with blood sugar problems being passed on to the baby.    Looking up “pregnancy related diabetes”  online, reading about possible severe consequences.

No one considered that there is absolutely nothing in Qing’s history to suggest a blood sugar level problem.   She eats nutritious food, not too much by any means.  No weight problem.   She eats almost no sugar.   Previous blood tests were normal.   The day of the abnormal blood test, the stress of the day was abnormal (stress can trigger a high blood sugar level, as does eating).   And the abnormal result was only a little bit abnormal.  If the doctor had five minutes to ask a question, or consider the case, ask what Qing had for breakfast, or, maybe, physically look at Qing, she might have had another idea.  But no one thought about this.

We got two days of the blood tests, at 11, 3, and 9.   Don’t ask about logistics of getting them.  All results came back normal.   Went back to the doctor in about a week, brought the blood test results (you maintain your own medical records in China.   Doctors and hospitals don’t do that.   Again, personal responsibility for medical care).     Doctor said everything looked fine, and Qing did not have diabetes.    What could have caused the one abnormal test?   “I don’t know.”   Other than what she ate that morning, or the timing of the test after eating, or extra stress.   An erroneous test result, perhaps?    The doctor obviously did not have time to look it up on Wikipedia.  

 By the way, our doctor came to us via some excellent guanxi.  Many women with excellent connections were also vying with us in the lines.

So if looking for optimization in health care, we are back to mystery.   Some system, some procedural value, could be optimized, but I can’t see it myself.    Not the doctor’s time, not the efficiency of the fee collection, not the minimizing of medical error.    Not the time or care of the patients.   It is quite clear, from all hospital experience, that people’s time has no value in this system.   The procedural system might be maximizing the number of jobs, but there are too many things that get done by machine that could be done by people, if desired, and one does not get the overstaffed-and-underworked sense of employees in hospitals that one gets in some other systems in China.

And perhaps my western mind just doesn’t see what is going on.   It often seems that Chinese are playing a different game, a bigger game, than we are used to confronting.    So maybe system design is not about maximization, but about conservation.   Perhaps system design is not optimizing anyone’s interests, even those of long-gone bureaucrats.   Perhaps optimization is not now, and never has been, the goal.   The goal, perhaps, is something bigger.   What is the takeaway from the incidents of confusing building layout, process preservation, paperwork adoration, standing in line for hours, inability  to schedule appointments, inability to check a result with a phone call or an email, and inability to ask questions? 

What clearly is being conserved is the grinding.   The grinding down of personality, of rage at stupidity, of the sense that things should work better.   It is the poverty of imagination.   The system is conserved.    Maslow is right – self preservation is always the first and foremost priority.    Hospitals in China never go out of business, and clearly don’t compete.   The system grinds slowly, but it grinds exceedingly fine.   The system truly is god-like. 

Health Reform, 2010

May, 2010 

Brenna and I had colds.   Not so bad, but she wanted to go to Shanghai to the Expo in a few days, so I thought we should make sure there was no serious problem developing.   No fun walking around the Expo with some hacking cough.

My cough had descended into my chest, sort of a bad sign, so I called my people at the school about a medical visit.

Pay first, then see doctor … about $0.58 … each

Students here seem to get sick a lot, which I attribute to the lack of heat in the dorms when it is actually freezing outside, or maybe to their relative lack of exposure to coffee, sugar, fat, and high-fructose corn syrup.  Anyway, a lot of students call me to say that they are in the hospital, for two or three or five days.    They are being treated for some variation on cold like symptoms.   I did not want some school nurse telling me I had to go to the hospital for three days.   I was not that sick, and neither was Brenna.   What I wanted was to make sure we did not have some weird disease, and if needed get a shot or some medicine stronger than coffee, sugar, fat, and high fructose corn syrup.

The school arranged a car and driver to take us to the real hospital, not the school clinic.   (The school clinic is where the students go, and the faculty also unless they have something really serious).

Those who think that China is some mono-formulaic culture, with no innovative capability, are, of course, wrong in many ways.  In the US, we have been using public private partnerships to bring more flexibility and cost control to construction and management of projects. So, too, in China.  Our school, ZUST, is a government school, but the management of daily maintenance, cleaning, food service provision, is contracted out, just like in regular American schools.

Contracting out includes providing the school with cars and drivers for transporting faculty to far off meetings, or picking up people from airports, or taking foreign experts like me to the hospital.   The cost is not small.   A trip to the Hangzhou airport is billed at about 250 rmb, which is about $36.   A taxi is a little more than half that amount (note – this was in 2010).   But, convenience and no buying of cars and servicing them and depreciation and driver overtime and health care and pensions and vacation pay (not).   Whatever.

The cost for a trip to the hospital, near xihu, should be about 75 rmb if done in a taxi.  About $11.  For the school car, the cost is double (they want to charge for both directions) – rmb 150, about $22. The school will pick that up, of course, for foreign experts like me. Not for regular faculty.   “Take the bus.”

It probably would have been possible to navigate through the hospital without assistance from someone who speaks Chinese.  Pretty much everyone working in the hospital has had at least some English, many probably have a lot of English, and pointing at my throat and coughing works pretty well as an indicator of the problem.

I took along some reinforcements anyway.   Dr. Dang, the Ph.D. marketing professor, agreed to go along and manage the process for us.  Good idea, since I did not know the procedure anyway.

Once in the door, one is directed to the payment window.   This is the Chinese version of giving people at the front desk your insurance card.   No need to sign waivers of anything. No need to show passports or proof of employment at the school.  “Sick?  Ok. Pay up.  Sign here.”

Economics suggests that in a monopoly system, prices should be above marginal cost. Economics also suggests that if prices are too low, the system will be abused and there will be excess demand, and probably long lines by which to ration care. So we have a problem here, as you shall see.

There were, in fact, two people in line ahead of us to pay our visit fee. We must have stood in line for at least three minutes, waiting, waiting, waiting.    When we got to the counter, we explained the reason for the visit (so the clerk could direct us to the right department), she handed us a bill for this initial visit.   Total for Brenna and me, 8 rmb.  $1.16. $0.58 each.

We were directed upstairs to the respiratory department (I know, because all the signs are in English, and even in Chinese).    Again, there was someone ahead of us seeing the doctor.   We were forced to wait in the hall, again, for what seemed like ten minutes but was probably more like five.

We walked in, explained our problem to the doctor, who listened to our chests, asked a few questions (fever?  How long?  Other medical problems?)  and prescribed some medicine.  I asked if he was giving us zhongyao or xiyao, Chinese medicine or western medicine.   He laughed, and said we were not sick enough for zhongyao, but he would give us some anyway.

I think if we had had more time, I could have asked him what he thought of the Knicks and Bulls, but we wanted to get out of the hospital so we could go shopping.

We went back downstairs to the pharmacy, stood in line once again for about three minutes, gave the clerk our prescription, and waited.   And waited more, this time for at least five minutes.    We got bottles of Robitussin, just like in the US, but with Chinese labeling.   But Robitussin, in the same style font and package design.   Just like in Walgreen’s.   And some zhongyao, not like in Walgreen’s, but take two pills twice a day.

The pharmacy cost was a little high. Total for Brenna and me, the same medicines for each, about 200 rmb, about $29.  Dr. Dang said that the pharmacy is where the doctors make their money, since they receive- I dunno- commissions, or kickbacks, or profits, or something from the sale of the meds.   Just like in the US. Hard to support a family, I guess, on doctor visits of $0.58.   Even in China.

To celebrate, we let the school driver go home alone, and we went shopping for coffee filters. Carrefour, the French retailer, was about three blocks from the hospital.

But the cost of the car and the driver was only about 50 rmb less than the cost of the doctor, the hospital, and the medicine.   I could write more about this, but I will let you all have that discussion.   Socialized medicine.  Gini curve.   Price above marginal cost.  Returns to education.   Benefits of being the odd one in the group.  And, as you will see below, maybe the perils of underinvestment.

Health care in China is not always wonderful.   A good friend of mine had thyroid cancer several years ago, had part of her thyroid removed, and now takes thyroid medicine every day.   Not such a big deal.   But the dosage of the med needs to be carefully controlled, because the side effects- sleeplessness, irritability, inability to concentrate- can be significant.

China does not have a history of personal physicians.   You have a chart, and whichever doctor is available when you come is the doctor you see.   Sort of like buying hot dogs at the local stand.   You can’t always get your dog from Mortie, the guy who gives you extra fries with that.   Personal physicians are available, of course, but that gets into money that most people do not have.

So the monitoring of the meds can be a little iffy.   Doses need to be changed with body changes, and it seems that not all doctors are equally well-informed about practices.    My own online research suggests that beta blockers can be used to mitigate the side effects, but Chinese doctors do not want to add a medicine on top of a medicine.   Bad harmony.   So side effects are just that.   Side effects.   Live with it.

My friend is in Dalian, which is an international city on the coast.   Not some rural county in the interior.   But the ranks of cancer specialists seem a little thin.  Using a little of my guanxi, I called a zhengfu guanyuan government official IIT student who is a doctor, to see if he could find better treatment for my friend than she was getting.  We got referred back to the same doctor my friend had been seeing.    So no progress there.  Maybe she is getting the best care there is.

I am sure there is a way to deal in a more sophisticated way with thyroid cancer side effects, but I cannot find it.   But I have never before confronted the possibility that there might be better care easily available, but I could not have it.   That’s what I get for living in a city in the US.   But my guess is that even with better universal care in the US, that possibility will confront more and more people over the next couple of decades.   Rationing, not by price, but by location.   I know this has been the case in poor areas in the US, and in China, for as long as there has been sophisticated medicine.   If you want to drive a few hours to get treatment, maybe you can have it.   But if you need to do that every week, or every two weeks, or once a month, better be prepared to not use up sick days for other illnesses.    I have already seen that for specialty surgery in the US.   I won’t be surprised to see it extend to more prosaic treatment, as rural areas empty out.

People suggest that China will become more like the US, and the US will become more like China.    Could be right, for more things than we think.