Jun 13, 1979 - king and followed a southwest course ending in Kwang- chow, with ... Mechanic, Graduate School of Social Work, Rutgers University,. CN 5058 ...
Commentary
Ambulatory Medical Care in the People's Republic of China: An Exploratory Study DAVID MECHANIC, PHD, AND ARTHUR KLEINMAN, MD, MA
Abstract: One hundred thirty-eight persons in varying outpatient settings in the People's Republic of China were interviewed briefly. Hospital outpatient utilization appeared to reflect not only severity of illness, but also patients' attitudes and beliefs, illness behavior patterns, and convenience, modifying the for-
mal system of care to some extent. Traditional clinics in commune and county hospitals were typically used to treat psychiatric disorders (defined as physical conditions), chronic illness, and other conditions for which Western medicine offers only symptomatic treatment. (Am J Public Health 70:62-66, 1980.)
With the formal recognition of the People's Republic of China (PRC) and the establishment of diplomatic relationships, there will be increased opportunities for many American physicians and researchers to visit China. It is to be hoped that there will also be occasions for medical research exchanges allowing in depth investigation. Much of our understanding of health care in China in the foreseeable future will depend on the observations of knowledgeable informants and visitors. Here we review some of our own experiences in trying to make the most of our China visit. To understand any nation, knowledge of its culture, language, and history is essential. Even with such preparation, the pressures of time, limited contacts, and the vastness of the country itself make reliable judgments difficult. Lack of expertness about China and its language* makes it difficult to evaluate in any rigorous way what one sees and what one is told. Our ten-member delegation began its 25-day trip in Peking and followed a southwest course ending in Kwangchow, with additional major stops at Tachai, Sian, Changsha, Kweilin, and Nanning. We spent most of our time in
rural areas visiting production brigade health stations, commune and county hospitals, traditional Chinese medicine hospitals, and anti-epidemic disease stations. We made efforts to gather as much health data as we could. It often became apparent, even with the most cursory questioning, that the population statistics on which rates were based often were uncertain, that the Chinese use different definitions than we do, and that the figures given us were confused because of misunderstandings. On the basis of information provided, it was often possible to do quick calculations that demonstrated consistencies or inconsistencies. Several members in our group, for example, had an interest in family planning efforts in China and, in many areas we visited, the Chinese reported considerable success in fertility control. Often they were able to provide data that supported these claims. Cross-checking convinced us that the Chinese were indeed making excellent progress. For example, in visiting maternity hospitals, we made rapid checks of the parity of individual inpatients; as we walked in villages and on city streets, we asked adults with children how many children they had or asked children how many brothers and sisters they had; we even asked older persons how many grandchildren they had and if they wanted more. The observations we made appeared to be consistent with the reports Chinese officials gave on success in family planning efforts. In the beginning of the trip, we would occasionally stop as we were walking through outpatient departments and engage in short conversations with patients. As we discussed this experience, we thought the exercise might be more valuable if we could collect cases more rigorously. For the next day or two we experimented, seeing if we could disengage from the rest of our delegation touring a hospital and inter-
From the Graduate School of Social Work, Rutgers University, and the Department of Psychiatry and Behavioral Science, University of Washington-Seattle. Address reprint requests to Dr. David Mechanic, Graduate School of Social Work, Rutgers University, CN 5058, New Brunswick, NJ 08903. This paper, submitted to the Journal June 13, 1979, was revised and accepted for publication August 17, 1979. Editor's Note: See also related editorial, p 9, this issue. *One of us (AK) was able to understand and speak Chinese and conducted most conversations directly. In some areas, assistance in translation was essential because of language variations, and local translators accompanied us.
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COMMENTARY
view patients in various outpatient clinics. When we realized it would be possible to do this, we tried systematically to cover certain types of information in each interview and obtained information from 138 patients. The data were deficient in many ways, but they provide a more systematic assessment of the functioning of the medical system than if we had simply followed the usual pattern of walking through the various services of the hospital asking occasional questions. A short description is required of the way Chinese medical services are organized in order to put the results of these brief interviews in context. The general logic of the care system is to create facilities related to one another that progress in complexity in relation to the need for more sophisticated technology and personnel. Officials of the People's Republic of China describe the rural medical care system as having three tiers, beginning at the production brigade health station staffed by the barefoot doctor, a paramedic with three to six months of training, assisted by midwives and health aides. The second level is the commune hospital, a modest health center or hospital facility with a limited number of inpatient beds staffed by Western and traditional doctors, nurses, and other health workers. The third level is usually a more sophisticated health facility organized by a municipality, county, prefecture, or province. A variety of specialty hospitals also exist for tuberculosis, mental illness, leprosy, cancer, eye problems, etc. Thus, depending on the locality in question, the care system has four or more formal tiers as well as the more informal treatment modes including self-treatment, the direct acquisition of herbal remedies and Western drugs from pharmacies, and the use of "folk practitioners." In theory, the production brigade should be capable of dealing with common health problems and account for 70 per cent of the necessary medical care. The barefoot doctors are expected to know their limitations, to recognize cases beyond their competence, and to refer them to higher levels of care. More complex problems are referred to commune, central,** county, and provincial hospitals, depending on the nature of the case, expectations of the patient, and the organization and ecology of medical facilities in the immediate area. Every hospital we visited from the small commune hospital to provincial hospitals and the hospitals affiliated with medical schools combines referral practice with the treatment of ordinary primary care problems. At each level at which we interviewed patients, the presenting complaints included significant numbers of patients who could be treated capably by a primary care practitioner. This occurs because each hospital usually takes responsibility for providing ordinary care to patients in its immediate geographic locality. Second, many hospitals had contracts to provide care to workers in factories, mines, and other state industries in their districts. Third, some patients bypassed the barefoot doctor in the production brigade, either because of the perceived seriousness of their condition, or because they lacked full confidence in the skill of the barefoot doctor. Fourth, **A commune hospital with somewhat greater technical sophistication than other hospitals in an area which offers technical support to selected commune hospitals.
AJPH January 1980, Vol. 70, No. 1
some patients had particular preferences for specific types of care such as traditional medical diagnosis, or Western medicine, and thus sought out this source of care. Finally, many patients appeared to have been given "provisional referrals" from the barefoot doctor. For example, they would see the barefoot doctor and receive treatment for their complaint. They would then be instructed that if they did not get better, they ought to go to the outpatient department (OPD) of the commune or county hospital. Although some of the interviews had considerable depth, most were very short, and we were able to code successfully only nine pieces of information: sex; province; rural-suburban residence; type of provider; type of referral; first or repeat visit; age of patient; and two major symptoms. We tried to code self-medication by Western and Chinese medicine, but it was impossible to determine if these remedies had been previously prescribed or were completely selfinitiated. In coding symptoms, an attempt was made to use the categories of the most common symptoms or complaints in the United States National Ambulatory Medical Care Survey (NAMCS),' but because of the differences in context, the small sample, and the limited degree to which patients specified their complaints, we were forced to adopt cruder
categories.
Analysis of Interviews Of the interviews obtained, 28 per cent were in Shensi Province, 30 per cent in Hunan, 20 per cent in Kwangsi, and 23 per cent in Kwangtung. Sixty-one per cent of interviews were done in facilities we defined as rural, and 39 per cent in facilities we defined as suburban-rural. The interviews in Shensi (in the Sian area) and in Kweilin (in Kwangsi Province) were coded as suburban-rural. Fifty-seven per cent of the patients interviewed were male, 38 per cent female, and the rest were infants or children whose sex was not specified. Twelve per cent of all interviews were obtained in traditional Chinese hospitals, and an additional 15 per cent in traditional Chinese clinics in commune and county hospitals, while 49 per cent took place in commune hospitals and 20 per cent in county hospitals, leaving only 7 per cent that were obtained in production brigade health stations despite our repeated efforts to enlarge this portion of the sample. Table 1 contains an extended description of primary presenting complaints, and Table 2 shows their combination for the purpose of cross-tabulation analysis. Table 2 also shows the secondary complaint. As indicated in Table 2, the vast majority of presenting complaints are for common problems. Because the majority of interviews took place in the southern part of China during the summer season, the frequency of gastrointestinal problems is not too surprising although this category accounts for one-fifth of all cases, more than we would have anticipated. Colds and musculoskeletal complaints (particularly back pain) were very frequent. The secondary complaints are fairly consistent with the primary symptoms, although relatively more complaints are found in the categories of headache and fever, and neurasthenia. This is in part a result of the way 63
COMMENTARY TABLE 1-Primary Presenting Symptoms or Complaints among 138 Chinese Patients Symptoms or Complaints
Cold Abdominal and stomach pain Pain or swelling of musculoskeletal system Headache Gastritis or upset stomach or enteritis or ulcer pain
Cough Eye problems Bronchitis Arthritis Skin irritations or reactions Wounds of skin or trauma Diarrhea Physical examination, checkup, or family planning advice Tooth problem Palpitations High blood pressure Symptoms of heart Female complaints Asthma Sputum or phlegm (purulent) Sore throat Neurasthenia or mental health problem Depression Hepatitis Vomiting Other complaints
N
%
14 10.1 13 9.4 11 8.0 9 6.5 8 5.8 7 5.1 6 4.3 5 3.6 5 3.6 5 3.6 5 3.6 5 3.6 4 2.9 4 2.9 3 2.2 3 2.2 3 2.2 3 2.2 3 2.2 2 1.4 2 1.4 2 1.4 2 1.4 2 1.4 2 1.4 10 7.2
proportion of "other" symptoms and follow-up care in the NAMCS study, it seems apparent that the proportion of mental health problems and visits relating to the eye are more common in the American sample. Reported heart problems appear to be more common in the Chinese sample. We found that a wide range of illness was treated at all levels of care. Some illnesses, however, were more commonly treated at some institutions rather than others. For example, most psychological problems we identified were treated at traditional Chinese medical clinics in commune and county hospitals. Although only 4 per cent of all complaints were in this category, 24 per cent of all patients interviewed in traditional clinics in these types of hospitals had such primary complaints. Similarly, although 8 per cent of identified secondary symptoms were in this category, 35 per cent of patients in traditional Chinese clinics reported comparable symptoms. This was in sharp contrast to the traditional Chinese hospital which had no more complaints of this kind than the sample as a whole. Interviews with both patients and hospital personnel suggested that doctors in internal medicine and other specialties referred patients with psychological problems as well as patients with chronic pain or intractable chronic illness to the Chinese medicine clinics in their hospitals. Traditional Chinese hospitals, on the other hand, were integrated into the local systems of care we visited with general medical care responsibilities and services for the localities they served as general hospitals. Hence patients come to these hospitals with a wide range of complaints. Musculoskeletal problems and reported arthritis were more frequent among the patients seen in traditional Chinese hospitals and the traditional Chinese clinics in commune and county hospitals. There were no large differences in presenting complaints between men and women nor was sex related to type of referral or type of provider. Symptom profiles were similar in residents of rural and rural-suburban areas. In the 60 hospital outpatient cases for which we had adequate information to categorize referrals, only one-third of the patients reported being referred by barefoot doctors. Self-referral was most common in patients attending county hospitals and traditional Chinese hospitals and least common in patients attending traditional Chinese clinics in commune or county hospitals. Patients making revisits were older than other respondents and more likely to complain of musculoskeletal, chest, and eye problems. Older persons were more likely to be seen in traditional Chinese clinics of commune and county hospitals. Acute conditions were more common in children and young adults. All these data are consistent with expected disease profiles by age and our impression of the way these varying facilities were used.
data were coded. For example, patients reporting sore throats might also report headaches and fever. Although the sore throat was coded as the primary symptom, the fever would be coded as the secondary symptom. In the final column of Table 2, data from the US National Ambulatory Medical Care Survey of patients seeing a sample of office-based physicians are shown.*** Although these data have not been published, the National Center provided the authors with a printout of the entire distribution of symptom code estimates for the US population in 1976. We tried to combine them in a way that resembles the classification of Chinese data as closely as possible, but with only partial success. For example, 14 per cent of the NAMCS visits are for follow-up care and progress visits, but in the China data we coded the complaint regardless of whether it was initial or follow-up care. Also, in combining categories in the NAMCS data, we used many estimates based on very smill sample sizes, possibly distorting the categories. The two data sets, however, give us a rough idea of the way patients compare in the two countries. If follow-up care and progress visits are excluded, there is a fair degree of similarity in the relative frequency of different types of complaints. The Chinese sample reports considerably more abdominal and stomach distress, but colds, sore throats, and complaints of the musculoskeletal system are very high on both lists. Taking into account the larger
Discussion
***In this survey, the physician completed a form for a sample of patient consultations that includes recording in the patient's own words the principal problems, complaints, or symptoms that led to the visit.I
These data have obvious deficiencies, but certain impressions are sufficiently clear, internally consistent, and consonant with what we heard and saw more generally that we can report them with some confidence. As in many other
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COMMENTARY TABLE 2-Primary and Secondary Presenting Complaints (Recategorized) of Chinese Patients, Compared with Patients in the U.S. National Ambulatory Medical Care Survey Secondary Complaint
Primary Complaint Presenting Complaints
1. Abdominal and stomach distress; diarrhea; gastritis; enteritis; vomiting 2. Cold; sore throat; cough 3. Pain or swelling of musculoskeletal system or reported arthritis 4. Headache and/or fever 5. Skin irritations or wounds or slight trauma 6. Heart problems, palpitations; high blood pressure 7. Pneumonia; asthma; bronchitis; chest complaints 8. Neurasthenia, depression, anxiety; generalized multiple complaints; disturbance of sleep 9. Eye problems 10. Follow-up care; progress visits 1 1. Others 12. No symptom reported
Percent of Office
N
%
N
%
Visits, US 1976 NAMCS*
29 25
21 18
15 9
11 7
5 8
16 10
12 7
4 16
3 12
13 3
10
7
1
1
6
9
7
-
-
2
9
7
6
4
4
6 6
11 12 64
8
5 5 14 33 2
-
4 4 -
17
12
-
-
-
9 46
*Unpublished data from the 1976 National Ambulatory Medical Care Survey provided to the authors by the US National Center for Health Statistics. The authors recategorized the data to maximize comparisons with Chinese information as well as to take into account changes in coding in the NAMCS in 1976. The coding categones in the 1976 NAMCS are a slight modification of those reported by the National Center for Health Statistics, 1974. Vital and Health Statistics, Series 2, No. 63, DHEW Pub. No. [HRA] 74-1337.
medical care systems in the world, referrals to hospitals reflect not only severity and complexity of illness, but also patients' attitudes and beliefs, illness behavior patterns, and convenience and physical ecology. All types of conditions were seen at all levels of care, and the medical system was flexible in its response. The Chinese medical care system does not recognize and deal with psychosocial issues in illness, nor does it give much attention to any mental disorder other than schizophrenia.2 Many patients who by our criteria would be seen as suffering from the somatic expression of personal distress, particularly depressed patients (having symptoms such as terminal insomnia, headaches, tiredness, lack of energy, and multiple vague complaints), are typically diagnosed as suffering from neurasthenia, which is viewed as a physical disorder.3 This clearly sanctions a medical sick role for patients who otherwise would bear the stigma of mental illness. Our hosts admitted such stigma is still prevalent in the People's Republic. Hence the sanctioned medical sick role offers almost the only socially acceptable way to avoid the potential stress of daily work and political demands. Traditional Chinese medical clinics are frequently used to deal with such patients, as well as with chronic illness, chronic pain, and other conditions. Our hosts repeatedly told us that the cost of Western drugs was a heavy burden on the care system and, in the financial data we obtained at various production brigades, AJPH January 1980, Vol. 70, No. 1
we found that two-thirds to three-fourths of all direct expenditures were for drugs. Data obtained at various hospitals also showed that drug costs were often the largest component of direct hospital expenditures. We were told that acupuncture, herbal medicines, and other traditional remedies not only provided effective palliative care for many patients and were consistent with cultural expectations, but also were effective modes of cost containment. Such remedies were often tried prior to the use of Western drugs, although the reverse pattern was also observed. In one medical school psychiatric department we visited, acupuncture and herbal medications were being investigated for the treatment of schizophrenia with the hope that such treatment could be substituted for expensive Western treatments.2 The People's Republic of China has been remarkably successful in extending access to health care through the establishment of health stations in most production brigades. Although one may have reservations about barefoot doctors-i.e., the lack of uniformity in their training, and the lack of evaluation of their work-their abundant presence in the community must provide peasants with a great sense of security that there is a sympathetic person who is available to help when they require it and who can refer them to more sophisticated facilities if necessary. In addition to first-line medical care, the barefoot doctors are active in immunization, family planning, improved sanitation, and health education, and provide an appropriate commitment to the environ65
COMMENTARY
mental forces affecting health and disease and the quality of rural life. The barefoot doctors also train health aides, frequently plant and harvest medicinal herbs, and do a considerable amount of agricultural work; their productivity more than repays the cost of their training and maintenance. A major issue in using practitioners such as the barefoot doctor is the degree to which they understand their limitations. Excessive referral is, of course, costly to the health brigade insurance system, which is developed on the assumption that the barefoot doctor can manage appropriately common conditions in the community with least cost. An epidemiological study of patients coming to production brigade health stations and of referrals would be necessary to appraise this issue adequately. Chinese health officials were modest in describing the accomplishments of their system, and they openly acknowledged the short and uneven preparation of barefoot doctors. They viewed such modest training as a necessary expedient measure to ensure health care services to a large and poor rural nation. Although we could note deficiencies in some of the diagnostic and treatment approaches we observed, we were impressed by the practicality of the health care system and by the wisdom of the priority at every level given to family planning, immunization, control of infectious diseases, improved sanitation, and better maternal and child
I
nutrition and care. Whatever the weaknesses of medical care in rural areas, the success in developing a rational rural health system with high priority on public health and one that is readily accessible to the population is a major accomplishment.
REFERENCES 1. National Center for Health Statistics. The National Ambulatory Medical Care Survey: symptom classification. National Center for Health Statistics, 1974. Vital and Health Statistics Series 2, No. 63. DHEW Pub. No. (HRS) 74-1337. 2. Kleinman A and Mechanic D: Some observations of mental illness and its treatment in the People's Republic of China. J Nerv Ment Dis 167:267-274, 1979. 3. Kleinman A: Patients and Healers in the Context of Culture: An Exploration of the Borderland between Anthropology, Medicine and Psychiatry. Berkeley: University of California Press, 1979, Chapters 4 and 5.
ACKNOWLEDGMENTS This paper is based on the authors' visit in June 1978, as part of the Rural Health Systems Delegation of the Committee on Scholarly Communication with the People's Republic of China, jointly sponsored by the National Academy of Sciences, the American Council of Learned Societies, and the Social Science Research Council. The views presented here are the authors' and not those of the Committee or Delegation. A more comprehensive delegation report is being prepared for publication.
Annual Symposium on Fundamental Cancer Research
"Genes, Chromosomes and Neoplasia" will be the topic of the 33rd annual Symposium on Fundamental Cancer Research to be held in Houston at the Shamrock Hilton Hotel, March 4-7, 1980. The symposium will focus on the relationship between genes, chromosomes and cancer with sessions covering chromatin and chromosome structure, the Sarc gene, gene expression, gene amplification, chromosomal changes associated with neoplasia and genetics of cancer. Co-chairpersons: Dr. Frances E. Arrighi, Dr. Potu N. Rao and Dr. T. Elton Stubblefield. For additional information: Stephen C. Stuyck, Information Coordinator, M. D. Anderson Hospital and Tumor Institute, Houston, TX 77030, 713/792-3030.
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