China and Environmental Protection: A Political Advantage

Three days ago, our host mother took us to a dinner celebrating the 15^th anniversary of an appliance company she had been involved with since 1998. The company specializes in boilers and A/C, and as the dinner progressed she told us a story that closely related to the topic we had discussed in class: China and the environment.

In 1996 when the company formed, the majority of homes in China were still being heated by coal, an energy source that is cheap and abundant in China but heavy in emissions of sulfur and soot. According to our host mo, in 1998 China instituted a national ban on domestic burning of coal in major cities, forcing people to shift toward cleaner sources of energy such as oil and natural gas. (I tried to confirm this ban online and found some vague support for it on Wikipedia…but no exact date, and other sources indicated it was carried out by city governments.)

The point here is that on the environmental protection front, China clearly has the political advantage in that it has a political structure that can simply make a decree and see it be done. The role of government will also likely be closely entwined to China’s shift toward cleaner sources of energy, as evidenced by the construction of the controversial Three Gorges Dam (produces 24% of China’s total hydroelectric capacity but displaces one million people…you gain some you lose some, I guess) and domestic ownership laws for green technology multinationals. All it needs is the political will to create a legal environment supportive of environmental protection.

Unfortunately, people higher up in China’s political structure are likely to oppose environmental protection measures on the grounds that it will stifle economic growth. According to our article, the State Environmental Protection Administration (SEFA) has been historically weak. Enforcement will likely be another stumbling block, as evidenced by a host of problems ranging from enforcement of smoking and traffic laws to issues with intellectual property rights.

One thing is clear though. On the green technology front, China seems to be far outpacing the US: http://www.economywatch.com/economy-business-and-finance-news/China-Green-Technology-Leader-Has-Future-Arrived-27-03.html (The article sounds reads with a slight alarmist tone and goes crazy with the hyperlinks but conveys the idea very clearly.)

Primary Care in China

Around this time last year, before I had set foot in China to do anything legitimate, I had sat down with an econ professor of mine to discuss a study protocol for the summer internship. “I’m not familiar with the Chinese health system,” he had told me, “but you should use their version of the primary care physician as your unit of analysis.” It was only after speaking with some doctors who had been working in China, and doing some literature research, that I came to an astounding realization:

China has no primary care system.

None, at least, until the recent few years. The closest thing was probably the barefoot doctors system of old rural China, a system that was dismantled in the 80’s with the opening up of the economy and the privatization of health care provision.

Today we visited a community health center (CHC) in Changsha. The remarks of the doctor who welcomed us further confirmed for me the infancy of the Chinese primary care system: according to him, the concept of a community health center only came about in the year 2000, and the recognition of primary care (全科医生) as a medical specialty didn’t happen until 3 years ago.

What sets CHCs apart from regular hospitals is their smaller scale, their focus on treating minor illnesses, and their responsibility for preventive health services. A 2006 paper reviewing the utilization of CHCs compared to hospitals noted 6 official functions of CHCs:

1. Disease prevention and control
2. Health surveys
3. Health education
4. Family planning
5. Medical treatment service (for basic illnesses)
6. Community rehabilitation

Yet of these, only the highlighted three were recognized by the people (>75% of respondents), and many elicited dissatisfaction, including a meager 21.9% satisfaction rate for medical service. Further data from the study confirmed that despite the existence of these primary care centers, people were going straight to the large specialty hospitals for treatment of any illness, acute or chronic, serious or minor. People might have to wait for days just to see a doctor, and healthcare bills continue to surge (charges at a hospital for outpatient service are almost 4 times as much as those at a CHC), leading to the well-known saying, “看病贵、看病难” (“seeing a doctor is expensive and hard”).

“Oh, community health centers…” my host parents had remarked with a twinge of hesitation, as if unsure why our program would choose to take us to one of those. “They can treat very basic illnesses, and people only really go there because they’re conveniently located.” Their attitude reflects a common mistrust of CHCs among the Chinese population, a mistrust that is often legitimate given the lack of resources and inadequate personnel that CHCs are plagued with.

Before we left, I asked our host doctor whether he thought the current trend of pushing patients toward primary care was necessary. “非常必要,” he had said. Yet despite the urgency, the local government has issued no concrete policies to encourage utilization of CHCs (although the local governor has called for it). The specific CHC we visited seemed to have enjoyed a burst of funding to build a new center, and national policy offers free preventive services for children and mothers. Whether this government investment can be sustained or increased, only time can tell. As healthcare costs and the demand for medical personnel grow in countries around the world, a key question for China as it moves forward is how it can instill in its people a willingness to seek primary care.

Slums and Ethics

On that same Saturday of the screening, I went up to the roof top of the church and met a couple of boys from the slum. We could only communicate in gestures and scattered English (the only thing I know in Tamil is “Hello” and “Let’s go”), but they took me around their home community in a trip that ended up with me in their house, surrounded by curious relatives and neighbors eager to take pictures and shake my hand.

I left a good half-hour later with a few phone numbers and a promise to return. That promise was fulfilled three days later, as I came back bringing a friend. This friend came for two main reasons: first because she was curious to see a slum in Chennai, and second because she was a teammate on a case study project assigned by our program. After some wandering, one of the boys I had met ran out and pulled us back into the house, where this time the family showed us their marriage photos and talked about their lives.

There are two layers of ambivalence that tear at me regarding these visits. The first is the question of power. To be able to walk into a community and be suddenly surrounded by strangers, to be welcomed into their homes and treated with respect even by those older than me…that’s possible only because I am an American. Traditional systems of respect, of forming relationships, had been immediately upturned due to no accomplishment of mine. And it’s always difficult to completely distinguish whether I was excited for the opportunity to glimpse into a foreign lifestyle, or simply excited to be worshipped. The second is the question of research. I’d be lying if I said that my second trip was for visiting purposes alone. I wanted to learn about the role of nutrition in a low-income family. There was no formal informed consent form, simply questions about food interspersed within talk about other topics of everyday life. And yet, ignoring for a moment the multitude of issues associated with transplanting notions of informed consent, I felt highly uncomfortable with having a research motive in the first place, a feeling similar to the one I get when witnessing fellow students grill “locals” about their perception of the healthcare system.

One final point. On the auto-ride here, my friend had remarked, “Sometimes I find that I underestimate the people I meet in developing countries.” Later, I would look around at the pristine kitchen, the organized schedules of classes posted on the walls marked clearly with official-sounding names of different classes, and realize that I had done just that. I had gone in expecting rice gruel and obedient wives. Instead I found a housewife-by-day, teacher-by-night and an aversion to beef for fear of high cholesterol.

PS. On the topic of ethics…I did ask for permission to post the photo above.

(Original post written 2/14/11)

Cataract Screening in Chennai Slum

Last Saturday I had the chance to experience a cataract screening in a slum of Chennai, carried out by Sankara Nethralaya (SN), one of the best eye hospital systems in all of India. Exhibiting the efficiency of a private company, yet funneling all profits into free services for the poor, unique non-profit hospitals such as Aravind, LV Prasad, and SN are a major factor behind the success of eye care and community eye health in India, catapulting India’s cataract surgery rate to about 5000/year/million population—about 10 times China’s current rate.

The screening was simple but efficient, carried out in a local church that acted as a sponsor. Patients moved from a registration table to a visual acuity and flashlight exam station, after which their results were recorded on a form and they were offered transportation to the hospital for definitive diagnosis and treatment. One, two, and three weeks after cataract surgery, patients are picked up and shuttled to the hospital again for follow-up and glasses. All free of charge. The sponsor system is an integral part of outreach screenings for SN; a sponsor (often a religious institution, corporation, or individual wishing to honor someone) will provide the facilities, feed the personnel (sometimes even the patients), and carry out publicity. Essentially they make the screening possible, and put it all on their own tab. “So why do people want to become sponsors?” I ask, trying to understand the incentives in this seemingly one-way arrangement. My host looks confused for a second, and then replies, “Sometimes people want to honor a loved one. Most of the time people just want to do their part to alleviate the suffering of the poor.” I’ve heard that line before, but there’s something about his voice that sounds sincere.

Following the screening, I was taken on a long tour (I’m talking about a good 2 hours of the administrator’s afternoon) of the Jaslok Community Ophthalmic Center, a branch of SN that focuses on community-based initiatives such as screening. The center consists of two sections: a paying section for patients who can afford it (it has A/C and some nicer waiting room chairs), and a non-paying section for patients getting free service. Profits from the one are funneled completely into paying for the other. The physical segregation is not something I completely understand (maybe paying patients need to feel that they’re paying for something extra), but I was assured that the treatment quality is the same.

The screening was… informative (trying to avoid terrible puns here but “insightful” and “eye-opening” keep coming to mind), but the real twist of the day came during a break in the screening session, when I met a couple of boys from the slum who offered to show me around. More about that in a soon-to-come post…

 

I’ve Got a Lovely Bunch of Coconuts

Learned how to split coconuts today using a simple contraption:

My host father then proceeded to explain to me how the coconut tree exemplifies the Indian notion of avoiding waste. The inside can be eaten. The middle layer can be used to make rope. The hard, outer shell is burned as firewood. The trunk of the tree can be used to build roofs. Even the stems on the coconut tree leaves can be collected and tied together to make a good broom. From top to bottom, every part of the tree is utilized.

(originally written 2/14/11)

Change…Or Simply Westernization?

It turns out that we aren’t the only group staying at the mid-range, distinctly Indian “Hotel Kanchi” in northern Chennai. Last night, a few of us met up with some newly hired Indian bankers (here for job training), and what began as “hanging out” ended up as a sharing of views on marriage, divorce, war, and gender equality.

“One thing we dislike about America,” they proclaimed, “is the loose sexual culture”. Fair enough. But what about arranged marriages in India? Shouldn’t marriage be a choice, and shouldn’t the decision to remain in a marriage also be a choice? Things are changing now in India, too, they tell us. It used to be that no one asked whether the woman liked the man she was marrying—now that is expected. And there are strict laws against domestic abuse. (Although a recent study showed that over half of married women in the slums of Bangalore experienced domestic abuse.)

Women’s empowerment is coincidentally the topic of discussion this morning. The speaker is from a local NGO that helps rural women secure loans to start their own businesses (not just Grameen-style microfinance, but for individuals as well), while providing some basic business skills training. The question is raised as to the expectations of women: if women are now moving into the workforce, are they still expected to fulfill all of their household and child-raising “duties” as well? If not, who’s going to raise the children, especially with the fracturing of the traditional extended-family household? “Well,” our speaker notes, “that’s part of the reason there’s been a proliferation of child care centers.” And elderly homes too, I bet.

“India…is on the verge of a great change,” my friend had pronounced the night before. The thing is, we say “change” to mean progress but what we’re really talking about is Westernization. Choice in marriage, gender equality, nuclear families, the institutionalization of child and elderly care…these are all ideas that originated from the West. Many of these values are admirable but there are some ill effects as well, and the challenge in shifting from simple Westernization to true “progress” lies in whether huge emerging countries such as India and China can develop while mitigating these excesses. China’s official stance has clearly and stubbornly been one of “modernizing with a Chinese touch”. I’ve already heard equivalent phrases here in India. Can it really be achieved, or is it all just rhetoric?

(Original post written 2/4/11)

Public Health: A Victim?

“The severe lack of funding for public health today is a direct result of the bad intentions of the private sector.”

That’s the assertion our professor threw at us to discuss today in class, as he played devil’s advocate to every person who had something to say. At first glance it sounds a little conspiracy-theory-esque. And I would’ve quickly blew it off if not for the provocative article I had read the night before.

It was an excerpt of a book on a history of women healers, recounting the rise of modern medicine in America and the denigration of women to the nursing profession. Hopkins was the first American medical institution reformed in light of the newly discovered germ theory of disease. Following its establishment, a man named Flexner went on a tour of American medical colleges and issued the famed Flexner report, naming which schools could remain open and which ones were closed. Coincidentally (?), the ones Flexner chose to close constituted a majority of schools open to blacks and women. Why? The commonly-heard argument is that it was simply a matter of performance. But tellingly, the medical profession then went on to demand the outlawing of midwives—at a time when midwives were more competent than obstetricians (according to a 1912 study published by—ironically—Hopkins). The punchline in all of this is that the initial Flexner study was funded by the Carnegie Foundation. It was funded by private sector.

Conclusive? Certainly not, especially drawing only from a single source with a pretty strong feminist/liberal tone. But provocative? Most certainly. Bringing the discussion back to public health, think about it this way: if we wanted people to be so healthy that the incidence of disease was minimized, public health would need to be going full throttle. But medicine would be out of business.

On the other hand, there is a case to be made for the idea that public health lacks funding because it is ineffective or inefficient (although this can quickly become a chicken-or-egg argument). Or that people instinctively lack faith in public health because its results are silent. Or, as one Wharton student put it, “public health fails because it’s carried out by the public sector and government is intrinsically inefficient.”

The crucial question is, does public health simply need more funding in order to succeed? Or is health on a large scale simply too complex, with too many influencing factors, that the field of public health is an inherently unsuccessful endeavor?

(original post written 2/2/11)

Telemedicine

Falling behind on posts due to lack of internet…the one below is actually from Switzerland, although I’ve already been in Chennai for a few days and am thoroughly enjoying it here. Apologies!

Anyway, back in Basel we visited Medgate, the largest telemedicine institution in all of Europe. Previously I had come across the concept applied to low-resource areas (to deliver care to places without doctors and hospitals), but this was the first time I witnessed the idea applied to patients in developed countries. Despite fears of increasing commoditized healthcare or strained patient-doctor relationships, the system appears fairly efficient, serving as a first-line service for patients and saving valuable time and healthcare resources. (The merits or dangers of such a system deserve an entire other entry.)

Instead, this entry is about an auxiliary program our presenter mentioned in the second-to-last slide: using telemedicine to help patients manage chronic diseases from home. I was intrigued. After the talk I spoke to the presenter and managed to get a visit to Medgate’s chronic disease management center (located in a different part of town). During today’s visit, two doctors showed me how their system works:

A patient receives a package including equipment for taking basic indicators (blood pressure, blood glucose, weight, heart rate, etc.) along with a neat little device that takes the data and transmits it to the central office. There, doctors and medical assistants monitor patients’ conditions, communicate with “house doctors” (primary care physicians), and counsel the patient by phone. My host showed me an example of a patient whose blood sugar readings over a course of a few weeks looks like a ski slope; highlighted points near the beginning indicate abnormally high readings, the house doctor was contacted, the medication regimen changed, and the patient’s blood sugar dropped gracefully to settle into the “acceptable” range.

I was impressed with its efficiency in a developed country such as Switzerland. I was really there to see if it could be applied to rural areas of developing countries. i.e. China, this coming summer. My proposed project is, in writing, centered around finding cataract patients…but if village health workers are interacting with villagers anyway, it presents the perfect opportunity to begin to confront the looming (and increasingly dire) problem of chronic diseases. There is currently—to my knowledge—very little infrastructure in rural China to help manage chronic diseases. Telemedicine may provide a promising method.

Of course, I will need to critically examine the need for such a system before thinking about ways to implement it, lest I fall into what a recent reading of ours called “the kid with hammer” problem—give a kid a hammer and he will think everything is a nail. A telemedicine system connecting village health workers and higher level hospitals is only necessary if (1) village health workers are unable to prescribe interventions to manage villagers’ conditions themselves, or if (2) village clinics lack the equipment, resources, or time to monitor patients’ health.

Three Days in Geneva

Lack of internet has made my posting a little delayed, but I wanted to take this opportunity to summarize three packed days in Geneva, the first stop of our semester-long trip. In those three days we visited a number of intergovernmental organizations with a role in global health: WHO, IOM, ICRC (red cross), UNAIDS, and the UN (You can look up those acronyms if you are really curious), culminating in a lunch with the health minister of India atop the roof of the UN building, overlooking a gorgeous Swiss landscape (yeah I know it’s not an opportunity we secured by merit in any way, but it’s still pretty exciting).

It’s both exhilarating and daunting to get a sense of the scope of decisions made here, by people who suddenly seem like human beings rather than fancy titles you read in published literature. It’s admirable to know these people have devoted their lives to the ideal of health for all. There’s just something so refreshing about the ideals of the ICRC, whose commitment to remaining a neutral, independent provider of healthcare to any person affected by armed conflict was personified so strongly by our guest Dr. S. That man is an unbelievable inspiration if you could hear him speak. Unfortunately, according to our professor, even the Red Cross is not immune from internal political power struggles.

That brings me to my second, more critical perspective. The global health landscape is facing some sweeping changes, changes that institutions such as the WHO must keep up with. There is a shift toward chronic lifestyle diseases such as diabetes and hypertension, even as global health seems myopically preoccupied with single diseases and short-term targets (As Dr. Chan pointed out, investing in health systems is not “sexy”). Investing in health systems is crucial to not only develop long-term self-reliance but also to ensure the success of disease-oriented programs such as those to combat HIV.

Perhaps the most striking part of these three days was not the grand buildings and the photo ops, but two stories we were told by our professor. The first is about cars. Whenever a new official is promoted to work in the WHO, you can usually find them by looking for the shiniest BMW. The second is about education. A year of elementary education at one of the greatest international schools in the world costs around $25K a year—good thing that it’s covered by the UN for its employees.

It’s stories like these that make you wonder at which point a grand dream for the world turns into a way for the powerful to spread their ideas while treating themselves. I’m not yet ready to agree with a statement as cynical as that. But as pointed out to me by those with far more experience, Dr. Chan’s was painfully honest in her recognition that the WHO is reaching a funding plateau and in her demand that it downsize to reduce organizational disarray and excess.

(Will post pics later, having a laptop crisis)

Snowed In!

Arrived in Boston last night via a 6-hour long Megabus ride. Staying at a friend’s house, who kindly picked me up from the bus stop and brought me to his home 20 minutes outside of the city.

I am now stuck in a suburb of Boston because of the 14-inch snowstorm.

A little bit of background about what I’m doing in Boston in the first place (since I just realized there have little prior information about this). This semester I am participating in IHP’s Health and Community study abroad program, a unique program that takes 30-some students to four countries to take a comparative look at health in a local context. I’m anticipating it will be a crazy adventure, full of learning opportunities not only from the places we visit and the people we meet, but also from the fellow students we travel with. (After reading some of their introductory emails, it seems like most of them are already seasoned world travelers.) Our orientation was scheduled to begin…in about half an hour in Boston. After calling IHP this morning, it sounds like I won’t be the only one arriving late.

This snow must be the first in many “unexpected schedule changes” they warned us about, and not only does it launch our program with an exciting start, it gave me an opportunity to speak with my friend’s dad, who must have one of the most exciting jobs in the world.

He’s a nuclear proliferation specialist and professor at Harvard’s Kennedy School of Government. His job takes him out of the country 2-3 times a month, and as he describes to me his experiences in Europe, Latin America, Asia, and the Middle East, I think how fitting it is for me to begin my own world exploration by gleaning experiences from someone who has seen so much.

One theme from his narratives sticks out to me—and that’s the theme of how much our view of the world is at the mercy of our media. We see ourselves as the bringers of democracy to the Middle East, liberators who will bring stability to the region. But local media in countries such as Iraq and Afghanistan are focusing on the civilian casualties, the wailing mothers in the streets, and ongoing controversy over the true numbers of civilian casualties, there is little doubt that local media are turning public opinion against us. A similar anti-American tint has been observed to run through Indian media. On the other hand, my friend’s father tells me that you would be surprised how friendly and pro-American Iranians are on the streets of Tehran. “The lesson here,” he concludes, “is that you really have to be out there to know what it’s like.”