Medical reform in Modern China – 回眸近现代中国医改进程 – English

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Medical reform is currently on everybody’s lips due to events in the last few decades. The focal point of medical reform exists as the problem of ‘difficult and expensive’. In fact, concerning medical problems in China, the problem has existed for more than 20 years. From the introduction of Western medicine into China, and the fight for dominance with TCM, to the patriotic public health movement, the ‘eliminate the four harms’ and the ‘barefoot doctors’ campaign, and finally to medical reform and opening up period, especially after the 90’s, with a long term perspective, China’s Medical Reform has already continued for more than 100 years. And if we are to investigate medical reform through the long course of history, we would actually discover that there are many worthwhile studies and that can be drawn from. Concerning the medical reform seen below, it is doubtless that there is still great progress to be made.

1. Political metaphor and collision of Traditional Chinese Medicine and Western Medicine

Chinese medical reform dated back to the period during which Traditional Chinese Medicine and Western Medicine (also called new med. And old med.) fought for medical dominant, and the nation established a formal medical system. this process was called “the nationalization of medicine”. obviously, there was deep social background behind the nationalization: political metaphor of “Sick man of East Asia” and the aggressive spread of diseases without the awareness of public hygiene.

“Disease” is exactly a metaphor. Susan Sontag had deeply researched this. She thought that a disease of body would transfer into a moral criticism and then became a Political oppression. Since modern times, Chinese people had been fighting sensitively under the metaphor and the shame of semicolony. Then, china started a long process of medical reform with the double requirement To actually change the health of Chinese people and to get rid of the discrimination.

Before the formal beginning of medical reform, TCM ,which comparatively progressed slowly and existed for a long time , conflicted and conbined with western medicine, and lost the dominance.

Before the 20th century, there was no national medical network either in the city or the countryside. In the city , doctors practiced medicine in hospital, and the countryside had a similar situation, but for the vast in territory, doctors would provide medical treatment at patients home. And the nursing is mainly completed at home, hospitalization did not exist.

Originally, Western doctors did not understand: Chinese doctors are not just experts at curing illness, they’re also community coordinators, social workers comforting their patients. For that reason, the modern clinics they established might cause fear among patients used to be treated at home.

In 1899, a British doctor called Howie performed his first surgery in China: the removal of a woman’s diseased eye. The theatre was very peculiar: the operating table was set under a tree, and surrounded by curious and suspecting villagers. When doctor Howie finished his operation, he returned the diseased eye carefully soaked in alcohol to the patient, because if he didn’t do that, rumours would spread and ruin his work. At that time, many Chinese people believed that Western missionaries were stealing organs from Chinese people to make medicine, because they could not accept that missionaries could build hospitals in China, and could not trust to receive cure in such an isolated and awe-inspiring medical environment.

1930年,还有人说西方医疗空间“宇墙崇闳,器械精良,由门而庭,俨如王者,病者受传呼而入,则入于博士诊病之室,白昼而玻窗也,必四围周以曼幔,绝不通一线之阳光,张电灯而从事,病者仰视,如见阎罗王”。As to Chinese medicine, it does not form a unified system, but all sorts of different forms of medicine that appeared over the course of its history survive alongside each other. In addition to traditional Chinese medicine, or ‘Confucian medicine’, there is ‘witch doctors’, ‘herbal medicine’, “游医”,以及在民间观念中并不属于医者范围的“接生姥姥”和“阴阳先生”,甚至是顶香看病的“香头”,这些力量都在和中国边缘的地带游走,深切地影响着民众的医疗生活。

直至1929年2月23日,国民政府中央卫生委员会第一会议召开,通过了《废止旧医以扫除医药卫生之障碍法》,另拟《请明令废止旧医学校案》呈教育部,这就是轰动一时的“废止中医案”,也导致了中医由原来的颓势直接变成了在国家医疗体系中的彻底没落。

2: towards a national system, the Lan Ansheng model

西医取代中医,一个重要的原因就是它契合了现代化政府的管理需要。在传统的城市里,政府机构和民间设施的边界是十分清晰的。在政府控制圈外存在着相当广阔的社会空间,如基层的自治互助组织、各种慈善团体和散布于各个区域的挂牌行业,这些组织有很大的自主性,管理上的时空区分并不明显。挂牌坐堂的医生随意分散在城市各个地方。而有组织有计划的西医和它的整个卫生体系能够把整个城市纳入其中,便于管理。自从采纳西医体系,中医也进入医院,中国传统中医和巫医“与天地通”的特色便渐渐不复存在。

这其中兰安生模式起到一个很重要的意义。上世纪30年代,美国人John B. Grant(中文名兰安生)担任北京协和医学院公共卫生系主任,他在北京设立了6个卫生试验区,覆盖了当时北京内、外城的大部分人口。这样,使医疗监控的区域扩大,并使医院医疗的空间和民众生活的空间被迅速结合起来。卫生区建立起来后,通过医护人员的不断登门访问,监控变得非常制度化。这一医疗模式被称为“兰安生模式”,后来在上海、天津、南京、广州等地区都建立了类似的卫生区组织。这样,医疗结束了散布民间的状态,被制度化了。

作为洛克菲勒基金会北加利福尼亚乡村卫生计划的成员,年轻的兰安生试图推动政府建立预防医学的意识,以弥合预防与医学治疗之间存在的分野状态。兰安生在中国出生长大,他的父亲曾是医学传教士。当医院病床不够时,他父亲会把病人带到自己家里,有一次,甚至把自己的睡床让给了病人。父亲对兰安生说:做医生不是单为了赚钱和治好几个病人,医生也应多关心社会问题。长大后的兰安生在约翰霍普金斯医学院学习。

全世界公共卫生学起步于第一次世界大战后,而兰安生面前的中国,并没有任何一个可以去实现公共卫生的基础元素:普遍贫穷、缺乏卫生设施、系统不健全、文盲泛滥、政府不稳定、没有任何现代的医疗保健系统。面对落后混乱的现状,兰安生开始了为医学社会化努力的历程,起点就是协和医学院的公共卫生课程,以及东城一座破庙改造的“卫生示范区”。当时协和有一股贵族气味,兰安生的到来,给正处在思想塑型期的协和医学生们,上了一堂堂生动的民生课,这些课的主旨是:走出医院,走进胡同,超越个体,关注更广人群,到达底层北京人生活的真实世界。在北京一座旧庙的基础上改造的卫生示范站,是1925 年兰安生与政府合作的结果,后改名为“北平市卫生局第一卫生事务所”,经过努力,十年中“一所”管理的居民区域,死亡率从22.2%下降到18.2%。

When Lan Ansheng was in China for sixteen years, he was full of dreams and passion, so much so that people started saying he was ‘a bolshevik of the medical profession’. When he died, he was awarded the highest recognition by the US medical health association, and recognised for its ‘great scientific foresight and statesmanship’.

3. Medical reform experiment: the dream of Cheng

After all, the construction of the “Lan An Sheng” model is a kind of urban behavior. However, in the countryside it is conducted by Chen Zhi Qian, a student of Lan An Sheng. Chen, a graduate of Xiehe, was influenced greatly from Lan An Sheng. Have attending one of Nan’s lectures, Chen was surprised to find the total difference between the lessons of the Public School of Hygiene and the previous traditional lessons. Lan An Sheng invited Yan Yangchu to Xiehu to instill strength into the doctors, by giving a lecture on the current social economic situation in the countryside of China. At the same time, due to the introduction of Nan An Sheng, Chen and Yan became friends, and then the model of the medical experiment of Dingxian and Chen Zhi Qian was at last realized.

At that time, the rural construct experiment was mostly concerned with rural health care, such as conservation of rural hygiene of Zhou Ping in Shan Dong, the Xugong bridge of Jiang Ling and the construction of a Farmer’s Hospital of Wu Jiang in Anhui, and so on. Amongst them, Ding Wian’s experiment, hosted by Yan Yangchu had the biggest impact. The rural construction experiment of Ding Xian started in 1926, and continued up until 1937 when the Japanese army invaded and occupied Huabei, the experiment was forced to stop. In 1932, Chen-Zhi Qian started an experiment in Ding Xian, during which the pioneered model of Ding Xian and village level 3 health care and became the model of that time.

In the model of Lan An Sheng, amounts of medical resources mainly concentrated in metropolitan centers, which are above the county level. How to make the resources used by countryside has already quickly became a content of rural social reform of that time. After the experiment of Chen Zhi Qian, he observed deeply that doctors trained in high level medical practice would stay in the cities and not leave. What’s more, the investement of the model of Lan An Sheng is too large, so it was only suited for big cities. As for this, he criticized that the best doctors should use the most advanced instruments and have the best bed-side manner. The most popular doctors in Chinese society work especially with a select few men and women in today’s society. Therefore, he mediated and put forward that the point of the rural medical reform consists in achieving two goals, including commercial medical prices, and instruments and localization of medical personal training.

“定县试验”建立起了较为完善的制度框架,形成了三级保健:县医院、乡卫生所、村保健员。当时,去协和医院住院看病都跟贵族似的,费用相当昂贵,但是协和医院有个社会服务部,每年会有一些预算给病人提供免费治疗,陈志潜等于把这种理念推广到定县,并且进行很严格的成本计算,比如一个老百姓一年到底能在治病上花多少钱,然后他按照这个数字来配置他的医疗体系,包括药的成本,他把它降到最低最低。陈志潜还从定县平民教育学校中抽调人员,培训保健员,他们从村里去,接受教育之后回到村里,背个药箱,里面有红药水、紫药水、一些基本的药,治些头疼脑热的病。如此就实现了“医疗人员训练的在地化”与“医药价格与设备的非商业化”。

美国作家赛珍珠,曾这样描述陈志潜的努力:“这是一个宏伟而永恒的事业,这个事业的无比正确和晏阳初、陈志潜制定的实用的计划的确令人信服,世界上没有任何东西能像一个已经成熟的思想观念那样有力量,平民教育和乡村改造的时刻已经来临,我们必须以更大的热情和决心向前迈进。”

后来的定县卫生保健的覆盖,扩展到了近50万人。“陈志潜模式”使得预防医学在乡村中扎根,并直接启发了后来的中国农村三级保健网和赤脚医生模式。他也由此获得了美国公共卫生界的最高奖章,被誉为“伟大的有科学预见性和政治家风度的人物”、“医学的布尔什维克”,对于我国公共卫生事业贡献巨大。可以说,他建立起了是世界上“第一个系统的农村卫生组织”。

4. Medicine under political discourse

After 1949, as China’s leadership was undergoing great change, the Health system also changed a great deal. The combination of medical and political movement was of great importance.

新政权成立后,在“面向工农兵、预防为主、团结中西医”原则指导下,针对当时对民众健康危害最大的20种传染病,如天花、鼠疫、霍乱等,开展了大规模的卫生运动,掀开了爱国卫生运动序幕。而高潮则是在1952开始的抗美援朝之后的“反细菌战”。这场运动在“抗美援朝”“保家卫国”等爱国主义的激发和动员下,迅速在全国展开,全国各阶层的群众积极地投入了这一运动中。仅半年,就清理垃圾7400余万担,疏通沟渠28万余公里,新建和改建厕所490多万个,改建水井130万余眼,全国共捕鼠1.2亿多只,灭蝇1300多亿只,很快控制了鼠疫等烈性传染病的流行。

而在1955-1965年间,抗美援朝结束后,爱国卫生运动进入了第二阶段。1956年,公布了毛泽东主持制定的《全国农业发展纲要(草案)》,提出了“除四害、讲卫生、消灭疾病”的任务。1957年,毛泽东还提出“在七年内,基本上消灭若干种危害人民和牲畜最严重的疾病”、“除四害,即在七年内基本上消灭老鼠(及其他害兽)、麻雀(及其他害鸟,但乌鸦是否宜于消灭,尚待研究)、苍蝇、蚊子”(后来麻雀改为臭虫)。当全国的指导思想是:要将消灭四害、讲究卫生、提倡体育,消灭主要疾病,破除迷信,移风易俗,振奋民族精神,作为向全国提出的文化和技术革命的重要内容,同时将之纳入国民经济建设规划。

1972-1977年间,开展的是“两管五改”的医疗方面运动。两管即管理粪便垃圾、管理饮用水源,两管后来又发展为五改:改水井、改厕所、改炉灶、改牲畜圈棚、改室内外环境。

在这些运动式医疗卫生建设期间,其中最为重要的无疑合作医疗制度与赤脚医生兴起。运动式医疗卫生建设本质上并不算是真正的医疗建设,而是卫生建设。但合作医疗制度的开始,则从医疗意义上开始了一次“医改”。现代医疗卫生建设的城市导向与无法适合农村需要的医学教育受到了毛泽东的严厉批评。在1965年6月26日关于卫生工作的谈何中,毛泽东十分尖锐地提出:“告诉卫生部,卫生部的工作只给全国人口的15%服务,而且这15%中主要还是老爷。更大农民得不到医疗。一无医生,二无药。卫生部不是人民的卫生部,改成城市卫生部或城市老爷卫生部好了。”对于医学教育:“现在医院那套检查治疗方法,根本不符合农村。”还有毛泽东甚至现代医生的口罩进行了批评:“医生检查一定要戴口罩,是怕自己有病传染给别人?我看主要是怕别人传染给自己。”

在毛泽东的严厉批评下,卫生部门迅速采取了有关措施。在呈送给毛及中央的文件中,卫生部表示:“今后要做到经常保持三分之一的城市医药卫生技术人员和行政人员到农村,大力加强农村卫生工作。”于是,巡回医疗在各地掀起了热潮。

在不断展开的巡回医疗过程中,参加巡回医疗的医务人员不仅积极开展了防病治病工作,也为广大农村培养一大批不脱产的卫生人员,从而既有效地缓解了农村缺医少药的矛盾,又在广大农村播下了大量医疗卫生的种子。而正是这些种子,成为了受人瞩目的“赤脚医生”。赤脚医生虽然现在看来,代表着简陋、落后的医疗水平,但对于当时的意义,无疑是十分重大的,这一点不能不客观看待。

到1976年,全国90%以上的农村都成立了合作医疗组织,从而形成了较为完善的三级预防保健网。在这个网络中,除了51万正规医生外,还拥有146万不脱产的赤脚医生,236万农村卫生员,65万农村接生员,中国农村基本上实现了“哪里有人,哪里就有医有药”、“小病不出村,大病不出乡”的目标。

另外,赤脚医生的特点是“从哪儿来到哪儿去”,他们中间有很大部分是由村里派到县里,培训一两个星期,最多两三个星期、一个月,再回到村里。这有一个好处,因为有一个亲属和亲情的网络,这就决定了他对农民的基本需要就有一种感情维系在里面,而不完全是政治口号、政治训练这样的因素起作用。赤脚医生本身也是本地人,他们的“为人民服务”是乡土化人情网络的自然结果。在上个世纪80年代的消失,使农村地区失去了一个有本土特色、便宜可亲的医疗网络。宗族关系和人际网络基本上决定了赤脚医生对于一个病人的态度,就形成了较为良好的医患关系。

合作医疗制度的确立和发展,有效地改变了我国农村长期以来缺医少药的状况,到70年代末,我国已经成为世界上拥有最全面的医疗保障体系的国家之一。

5. A return of the Medical system to normal, including inherent flaws.

After 1978, The National Health Campaign was added to the construction of socialist culture and ideology. The programs reached all levels of society down to country township level. Some examples include programs to eliminate localized diseases in the 50’s, and the ‘two controls and five reforms’ campaign. In the 70’s, the programs were gradually replaced by distinct city centered campaigns, such as the ‘medical school’ or ‘civilized city’ approaches.

Definitely, social medical work was expected to shake off the basic model of mass movement and ultimately become the work of medical experts, to underline and stress ‘high-end, advanced and effective’’ medical technique. 当时,有一些医学科班毕业的医生,他们发表文章呼吁,说赤脚医生不行,技术太差,只能满足头疼脑热的治疗,社会应该培养高精尖的医生。随后整个医疗体制开始改革,走向市场化,大量的投资进入城市,投资大医院,买先进仪器,转移之后农村赤脚医生的体系自然就瓦解了。

后来赤脚医生逐渐私人医生化,他们开私人诊所,私人诊所必然会计算药的成本,慢慢地亲情关系全被瓦解了。现在再恢复合作医疗很难,因为这个网络已经不行了,包括道德情感的网络,还有文化。

1985年,可以说是真正意义上人们关注的医改“元年”,当时卫生部提出“必须进行改革,放宽政策,简政放权,多方集资,开阔发展卫生事业的路子,把卫生工作搞好”。1989年,国务院批转卫生部《关于扩大医疗卫生服务有关问题的意见》,医改在争议中继续前行。

1992年,医改正式迈出“市场化”步伐。国务院下发《关于深化卫生改革的几点意见》,医院要在“以工助医”、“以副补主”等方面取得新成绩,医疗服务进入市场化阶段。2000年,公立医院产权“变卖”。国务院公布了《关于城镇医疗卫生体制改革的指导意见》,其中“鼓励各类医疗机构合作、合并,共建医疗服务集团”被解读为为“市场化”医改开绿灯。2005年,《中国青年报》7月28日刊出报道,披露了国务院发展研究中心《中国医疗卫生体制改革》课题组研究报告的主要内容,其中最引人注目的是其一个结论:“我国医改基本不成功”。

而后历经多年的争论,2009年4月《中共中央、国务院关于深化医药卫生体制改革的意见》和《医药卫生体制改革近期重点实施方案(2009-2011年)》出台,标志着最新一轮医改拉开帷幕,至今已三年。但这样的医改,就改成了现在这个大家众所周知的状况了。

Six, learning from history: Reform must serve the general public

总结可以发现,中国近代以来的医改改革,是从中医到西医的一个现代化过程,而到49年之后,医疗则作为一个政治话语来构建的,严格意义上说,大部分都很难算是医疗建设,而是卫生建设。在中国开始正式改革开放与现代化之后,医改则真正地开始构建一个现代化医疗体系的目标发展。但在这个过程中,政府显然在很多地方没有做好准备就贸然开始改革了,结果在往市场化改革这个正确的方向之下,却演化出了如今这医疗领域乱象频发的尴尬。

以史为鉴,不管是市场化还是其他思路,首先应该明确,医疗体系的构建,是为了保障全体公民的健康的,享有最佳的医疗是每一个人的基本权利。整个改革方向都应该一致的,为了民众拥有更好的医疗服务,低价、廉价甚至免费医疗,让人人都能享受到优质的医疗资源,而非成为谋取利益的手段,医疗不能完全商业化,需走出唯利是图的泥沼。

其次,政府应该牢牢记住,要把有限的公共资源用在其他非政府资源不愿意投入的地方,例如西部地区和广大偏远的农村,将注意力放在更广泛的底层。国家必须无条件无目的地承担起这方面的责任,实现全民的基本医疗福利保障。陈志潜与合作医疗制度之所以能够取得重要的成功与发挥巨大作用,正是基于此,一旦中国贫困地区与农村的医疗问题解决,也就基本上解决了中国的医疗的问题了。至于那些大城市和经济发达的地区,在医疗资源相对丰富的背景下,完全可以放开社会资本的进入,以社会资本促进医疗资源的增量,进一步废除医疗管制,规范真正意义上的市场化改革。

最后,必须破除当前医疗领域最为不公平的“双轨制”。据2005年中科院的一份调查报告称,中国政府投入的医疗费用中,80%是为850万以党政干部为主的群体服务的。这无疑是陈志潜与毛泽东所批评的服务于“老爷”与“阔老爷姨太太”的医疗了,与医疗改革背道而驰。当然,医疗事业的发展,也有赖于医疗工作者应该有着相应的职业素养与信仰。这些理念,应该牢牢贯穿到医疗政治实践的每一个过程。

(本文参考了杨念群《再造“病人”》、胡宜《送医下乡》等专著. For that, we wish to thank their authors.)

‘In the same boat’ magazine, 2012, issue 7

http://www.tongzhougongjin.com/column/speciallist/showspecial/?id=412

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Source : my1510

About julien.leyre

French-Australian writer, educator, sinophile. Any question? Contact julien@marcopoloproject.org