Chinese Doctors Tell Patients To Pay Upfront, or No Treatment
Parents of Boy With Leukemia
Scramble for Cash to Cover
New Chemotherapy Round
Threat Seen to Social Stability
BEIJING -- As soon as the money dries up, doctors warn, so will the drugs that could save the life of Cui Guangshun's 7-year-old son, Dejie, in the leukemia unit of Beijing Children's Hospital.
Such are the rules of China's pay-as-you-go health system: cash upfront, or no treatment.
Mr. Cui's wife, Yang Deyin, traveled more than 300 miles by bus to Beijing from their small farm on the grasslands of Inner Mongolia to be near her only child. For weeks, she camped out on a blue plastic chair in one of the hospital waiting rooms to save money on lodging, like dozens of other parents.
Back home, her husband pleaded with relatives and village neighbors for more loans to keep the boy's care going. Most nights, the mother queued up in a drab hospital lobby, littered with food wrappings and possessions, to use a touch-screen computer that told her how much of the family's cash was left. Sometimes the number flashed red, meaning the family was in arrears and prompting a frantic call to her husband.
In the past few weeks, Mr. Cui and Ms. Yang have been forced to accept a terrible reality: Even though their son's leukemia is considered highly treatable, they may never raise enough money to cure him. The hospital's estimated fees of $18,500 to complete an initial 6?-month course of treatment are impossibly high set against the family's annual income of less than $350. Like two-thirds of China's population, they don't have health insurance.
"There's nothing for it," Mr. Cui sighed, slumped in the doorway of his red brick home on a recent afternoon. He said he had dug up his potato crop and sold it all. He had threshed his corn and sold most of that, too, leaving barely enough to make the steamed bread that keeps his family going through the winter. "I'll just have to fetch Dejie home to die," he said.
The struggle of one couple to save their son highlights a growing crisis in China's health-care system, one that millions of Chinese face even in booming cities like Beijing, where the children's hospital is just a few minutes' walk from upscale hotels and office towers.
Xie Jing, the chief doctor responsible for Dejie's ward, defends her hospital's insistence that patients pay for treatment ahead of time by putting money into a hospital-controlled account. "If the patients have no money to refill their hospital accounts, we have to stop giving them medical treatment," she says. "It's a national problem."
Health care is an issue vexing the world's most developed countries, including the U.S., where people without insurance can lose all their savings if they get sick. But in worst-case scenarios, people who need urgent care generally receive it. In the U.S., a poor family such as Mr. Cui's would be eligible for Medicaid. Japan and most European countries cover everyone through universal health-insurance programs.
That's not the case in China, where patients are routinely denied care if they cannot come up with the money to pay for it in advance -- even in emergencies.
The World Health Organization ranked China fourth from the bottom of 191 countries in terms of the fairness of its medical coverage in a survey issued in 2000. This March, a report from a Chinese cabinet think tank said that unless China overhauls its medical care, "it will directly affect economic development, social stability and public support for reform."
The country's top leaders have expressed alarm about the inequities. President Hu Jintao has promised to overhaul the health-care system as part of his promise to build a "harmonious society."
The crisis in China's health-care system is already showing signs of holding the country back. Health-care costs are one of the main reasons Chinese save as much as 40% of their incomes. That is money they are not spending to consume more goods, as U.S. officials have been hoping amid concern about the big U.S. trade deficit with China. Fewer than one-third of China's 1.3 billion people have health insurance. More than half of all health spending is out of pocket, according to the think-tank report.
A year ago, Sam Lin, a prosperous factory owner, took his pregnant wife to a hospital in the southern boomtown of Shantou to give birth. As he recalls it, the couple were startled in the waiting room of the maternity wing by a commotion. A woman who had just delivered her baby was bleeding profusely and needed an emergency blood transfusion. Mr. Lin heard nurses screaming at the bleeding woman's husband. "If you don't have any money, we don't operate," one yelled, according to Mr. Lin. He says he rushed up to the man, counted out a stack of banknotes and thrust them on him. He never found out whether his charity saved the woman's life.
As recently as the 1970s, China's health-care network covered just about everybody. Collective farms offered basic treatment and immunization. In cities, health care was a perk of jobs in the government and state factories, which often ran their own clinics and hospitals. But as China embraced free markets, the "People's Communes" were disbanded in the countryside, and thousands of state factories were shut down or privatized. Starting in the 1980s, hospitals were ordered to turn a profit.
Today, China has plenty of large hospitals packed with state-of-the-art equipment to compete for paying patients. To maximize revenue, hospital doctors routinely overprescribe drugs and diagnostic procedures, according to studies by the Chinese government and international bodies like the World Bank. Hospitals sell many drugs directly to patients and add a profit margin.
A World Bank study estimates that drugs account for more than 50% of all Chinese health spending. In the U.S., prescription drugs account for less than 15% of total health spending, according to U.S. government figures. The World Bank study says 12% to 37% of Chinese national health expenditures are wasted because of unnecessary drug prescriptions.
"Hospitals have become huge corporate profit centers," says Chen Bowen, an official with the Society of Community Health Service, a nonprofit organization based in Beijing that advises authorities on health reform.
Gaps in the System
Government officials acknowledge the gaps in the system that make stories like Dejie's common. A Ministry of Health study in 1998 showed that 42% of people who checked out of hospitals discharged themselves, mainly because they had run out of money. Mr. Chen's research shows that in rural areas, 30% of children who die end their lives at home because their families can't afford hospital care.
At the Beijing Children's Hospital, doctors in the cancer ward quickly got to the bottom line. They explained to Dejie's mother that if the family's account dipped into arrears, that would be the end of the boy's treatment.
The hospital's Dr. Xie says doctors' income would be affected if they don't "push patients hard enough" to settle their bills. "Nowadays, doctors don't just treat patients. They've also got to chase for payment," she says.
According to hospital regulations, once patients owe more than $250, the doctor must issue a warning and take responsibility for getting the money. Usually patients pay in cash. Credit cards aren't widely used in China. "Hospitals are not charities," says Dr. Xie. "The biggest problem is the poor insurance system."
A hospital spokesman declined to comment on the case, referring inquiries to the Beijing Health Bureau, which referred calls back to the hospital.
Dejie first got sick with a cold in late September. For weeks before that, he had been complaining of fatigue and pain in his abdomen. The first doctor to examine the boy took blood tests but saw nothing suspicious, and prescribed stomach medicine and a cold remedy. By then, Dejie had turned a shade of yellow and was too weak to walk to school. A second doctor ran new blood tests but offered no better explanation.
Mr. Cui brought the boy to a larger hospital in the city of Chengde, five hours away by bus, where another doctor broke the news that he had leukemia. This doctor recommended they seek treatment in China's leading children's hospital in Beijing.
Mr. Cui recalls that when he heard Dejie had cancer, he stood in the road and sobbed. Dejie lifted his hand and dried his father's tears. "It broke my heart," he says.
Relatives describe Dejie as a studious boy who prefers staying indoors to playing outside among the chickens and pigs that run around the village. Mr. Cui has hopes his son will make it one day to college. He's proud of the way Dejie can memorize his school textbooks and boasts that the boy can even recite some passages backwards.
When Mr. Cui first carried his son through the front doors of the Beijing hospital in early October, the boy's once-ruddy cheeks had turned white. A chunky kid, spoiled at mealtimes by his parents, he was now so thin his father could gather him up in his arms like a baby.
Mr. Cui knew better than to expect any help from the government. He says the head of his village, a collection of 30 dilapidated homes reached by a potholed mud road, turned down his request for a loan, declaring Mr. Cui's collateral -- his house -- to be worthless. The local Communist Party secretary wasn't much help, either. "People die every day in China," Mr. Cui recalls him saying.
Mr. Cui imagined he had heard his son's death sentence. But at the Beijing Children's Hospital, a doctor put him straight. "If you have money the child can live," Mr. Cui recalls her saying. "If not, he will die."
Beyond that, there seemed to be nobody to guide a bewildered farming couple through the hospital bureaucracy -- even as the hospital's touch-screen computer showed they were burning through the equivalent of almost a year's income every day. "In this hospital," said Mr. Cui, "you get through money faster than toilet paper."
His parents couldn't bring themselves to tell Dejie he had cancer, but he found out from the other kids in the ward. The peasant boy with his strong country accent is a curiosity, and the other young patients have dubbed him Kentucky, as in Kentucky Fried Chicken, because of the way his Chinese name rhymes with the Chinese transliteration of Kentucky, which is "ken de ji."
The first round of chemotherapy lasted one month. Doctors warned that if they had to abandon treatment midway through the second round, when the boy's immune system would be shattered, he could easily fall prey to a life-threatening infection. But they went ahead anyway, with no guarantee that the family could raise more cash.
In China these days, the cost of serious illness quickly becomes a community burden. Of the 30 or so families in Guangming village, a settlement without electricity until 1996, half chipped in with loans that they could ill afford, Mr. Cui says. Those who didn't, he says, simply had no cash to spare. The All China Women's Federation drummed up support around the area with television appeals, as it often does when someone falls seriously ill. The stricken boy's classmates added their savings. Once, on one of Mr. Cui's visits to Beijing, the long-distance bus driver let him board free, and the conductor took up a collection among the passengers.
The strain of health-care costs is so severe it is plunging growing numbers of people back into the poverty from which they so recently escaped. At age 38, Mr. Cui is ruined, his debts of nearly $4,000 already amounting to more than 10 years of income. His relatives and neighbors who lent him money are worse off, too.
Medical horror stories have become a staple of Chinese state newspapers and investigative television shows. Last month, the China Youth Daily reported that the impoverished family of a 47-year-old migrant worker left her for dead at a crematorium in the eastern city of Taizhou after checking her out of a hospital where she was admitted with a brain hemorrhage. The woman was saved after undertakers noticed her hand moving and saw tears in her eyes. A hospital official confirmed the details of the story, and said the woman was now back in the hospital after donations poured in. The family apparently left her because they were too poor to pay for the treatment.
Such stories are fueling public anger. Mr. Chen, the Society of Community Health Service official, is helping the government stitch together a network of publicly funded community health centers, in effect replacing the system that was destroyed. But Mr. Chen says the effort will take up to 20 years. The government is also trying to build up the health-insurance system.
Admitting Defeat
On a late November day, Mr. Cui finally admitted defeat -- he couldn't pay for all his son's treatments. He tidied up the only heated part of the house back in Inner Mongolia, a cramped room with a concrete floor and bare walls. Mr. Cui and his wife were married there, and it contains their prized possessions: a thermos flask, a small television set, a red sofa. Below the window is a traditional heated platform bed, where Dejie used to snuggle warmly at night next to his parents and Mr. Cui's 80-year-old father.
The next day, Mr. Cui made the long road trip to Beijing and stood meekly by his wife as one of the doctors scolded them for getting behind on their payments. "We warned you about this at the very beginning," the doctor said, barely glancing up as her fingers tapped out a message on her mobile phone. "Now you've lost all your money and you'll lose the boy too." Mr. Cui stared down at his feet. His wife said nothing, but her eyes filled with tears.
Dejie is now midway through the second of five rounds of chemotherapy. Instead of resting in the care of nurses in the isolation ward, his parents checked him out to save money. It's a dangerous gamble with his compromised immune system. The boy is staying with an aunt in a village outside Beijing. This past weekend he picked up a cold. His father took him to the hospital briefly for treatment of the cold and as of yesterday, Dejie was resting again at his aunt's house.
His parents say they will deliver him back to the hospital in a week or so to try to complete the second round of chemotherapy with their last remaining money. But having checked Dejie out of the hospital, they will have to wait in line to get him back in because there are no beds available.
中国医疗体制下的严酷现实
那天，北京儿童医院的医生提醒崔广顺说，如果帐上的钱用完了，他儿子德洁用的那种有可能挽救他生命的药就得停。
这就是中国实行现收现付式的医疗体制带来的严酷现实，如果不先交押金，医院就不给病人治疗。
崔广顺的妻子杨德银从离北京500来公里的内蒙古草原的一个小牧场乘长途汽车来到北京，照料他们唯一的儿子。为了节省住宿费，几个星期以来，她就在医院一处候诊室的塑料椅上过夜。
而在内蒙古的家里，她丈夫到处找村里的邻居和亲戚东挪西借，筹到一点钱就寄到北京维持儿子的治疗。杨德银几乎每天晚上都要到医院一个装著触摸式电脑显示屏的走廊里排队，等著查查儿子的帐户上还剩多少钱。
不过，在过去的几个星期里，崔广顺和杨德银已经被迫接受了这样一个残酷的现实，那就是：即使他们儿子的白血病在医学上很有希望治好，他们也可能永远筹不到足够的钱给他治疗。医院估计，德洁的病要完成第一阶段六个半月的疗程大约需要18,500美元（人民币15万元），这笔钱对这个年收入不到350美元（约合人民币2,800元）的家庭来说简直是个天文数字。和中国其他三分之二的人口一样，崔广顺没有医疗保险。
前不久的一个下午，崔广顺靠在他家的红砖房门口说，生了病什么也没了。他随即叹了口气。他已经把今年种的土豆全部收下来卖掉了。玉米也全部收了，已经卖掉了大部分，只留下一些够全家过冬蒸馍吃的。他说：“我只能把德洁接回家等死了。”
这对夫妇为挽救儿子的生命而苦苦挣扎的情景正是中国医疗保健系统危机日益加剧的一个写照。即使是在北京等经济较发达的城市，也有数百万人面临同样的危机。
德洁的主治医生谢静认为医院严格坚持现收现付的做法是必要的。她说，如果病人的医院帐户上没有钱，我们就只好停止给他们治疗。这是一个全国性的问题。
医疗保健即使是对美国等世界最发达国家也是一个让人头痛的问题，在美国，没有医疗保险的人如果生了病就有可能花掉全部积蓄。但不管怎样，需要紧急救治的人通常
还是能得到救治，政府对享受税收减免的医院有这方面的规定。
在美国，政府分别通过联邦医疗保险计划(Medicaid)和老年保健医疗制度(Medicare)使低收入人口和老年人口享受公共医疗。在欧洲许多国家，政府医疗保障系统覆盖到每一个人。日本也实行普遍医疗保险制度。
但中国不是这样，许多病人如果拿不出足够的钱先缴上押金，常常只能拒绝治疗，哪怕患者需要紧急救治。
在世界卫生组织(World Health Organization) 2000年所作的一项调查中，在医疗覆盖情况一项，中国在191个国家中排在倒数第四。排名靠后的都是那些医疗保险水平低、且医疗开支入不敷出的国家，在这些国家人们经常选择放弃治疗。
今年3月，在中国领导人就医疗保障问题发表讲话后，政府的一个智囊机构也发表报告，回应领导层对这一问题的担忧。报告说，这个问题将直接影响经济发展、社会稳定和公众对改革的支持。
中国医疗保障系统的危机已显示出抑制国家经济增长的迹象。中国人的储蓄率之所以高达40%，存钱防病是其主要原因之一。由于这一点，中国人的消费开支受到很大限制，而美国官员和世界很多国家都希望中国人能增加开支。
在中国13亿人口中，只有不到三分之一的人有医疗保险，而保险还经常有缺口，在全部医疗开支中，有一半以上需要患者自掏腰包。
上世纪七十年代，中国的医疗保健制度覆盖到所有人。实行集体所有制的农村提供基本医疗和免疫接种。在城市，在政府机关和国营单位工作的人可以享受公费医疗，这些单位往往还都有自己的诊所甚至医院。
但随著中国向市场经济过渡，“人民公社”已不复存在，成千上万的国营企业也纷纷关闭或实行了股份制改造。从八十年代初开始，政府要求医院开始自负盈亏。
今天，中国有许多大医院添置了很多最新医疗设备以吸引付费的病人。但在医疗成本迅速上升的同时，医院的收费也在急剧膨胀。据中国政府机构和世界银行(World Bank)等国际机构的调查显示，医生通常会给病人多开药，或增加一些不必要的检查项目。
据世界银行的研究报告估计，医药费占中国医疗开支总额的50%以上，而其他大多数国家在15%-45%之间。研究报告说，医疗开支中有12%-37%的开支由于不必要的药品处方被浪费掉了。
民间机构中华医院管理学会社区卫生服务分会(Society of Community Health Service)主任委员陈博文说，医院已经成为一个庞大的集聚利润的地方。这家位于北京的学会为政府的医疗改革提供咨询建议。
政府官员承认，中国医疗体系的巨大缺口使德洁这样的情况非常普遍。据卫生部1998年作的一项调查显示，有42%的病人是自己主动要求出院的，主要原因是帐户上没钱了。而陈博文的研究显示，在农村地区，有30%的死亡儿童是在家里而不是医院去世的，原因是他们的父母拿不出钱让他们住院。
在北京儿童医院，肿瘤病区的医生们很快就不得不向德洁的家人发出警告了。他们向德洁的妈妈解释说：如果德洁的帐户上开始出现欠款，医院将终止给德洁的治疗。
主治医生谢静说，如果拖欠的帐单太多，医院就要承担经济损失。而医生如果不去尽量敦促病人补齐费用，他们自己的收入也会受到影响。她说：现在，医生不仅要给病人看病，还要催他们交钱。
根据医院的规定，如果病人拖欠的费用达到250美元（合人民币2000元），医生就必须向病人发催缴单，并负责催病人筹到现金。在中国信用卡还很不普及。
她说，人们因此对医院和医生很不满。但医院不是慈善机构。她说，最大的问题是医疗保险系统很不完善。
该院的发言人拒绝发表评论，并让记者将问题转给北京市卫生局，而随后卫生局又让记者给该院打电话。
德洁去年九月份得了一次感冒。在这之前的几周，他总说自己很累，肚子疼。第一位诊治大夫给他验了血，但是没发现任何异常，只给他开了一些胃药和感冒药就打发了事。但到了九月份，德洁已经面黄肌瘦，连上学的力气都没有了。第二位医生又给他验了一次血，但还是没找到原因。
崔广顺赶紧把孩子送到承德市的一家大医院，乘公共汽车需要5小时。那里的大夫告诉他一个如雷轰顶的消息：孩子得了白血病。医生建议他赶紧到北京，去中国最好的儿童医院诊治。
崔广顺回忆起得知孩子得了癌症的那一刻，他站在街上失声痛哭。德洁抬起小手，给父亲擦去眼泪。“我的心都碎了，”他说。
亲戚们都说，德洁是个勤学上进的好孩子，总在呆在家里，不出去乱跑。崔广顺一直盼著孩子有一天能考上大学。德洁能流利地背诵课本让他深感自豪，他还向人夸口说德洁对一些段落甚至能倒背如流。
十月初的一天，崔广顺带著孩子跨进了北京儿童医院的大门。德洁昔日红润的小脸现在一片惨白，曾经敦敦实实的身材现在骨瘦如柴，父亲把他搂在怀里就像抱著一个婴儿。
崔广顺除了指望政府救助，再也没有其他办法了。村长拒绝了他贷款的请求，说他的抵押物──房子──根本一钱不值。当地政府的党委书记也没帮上什么忙。“中国每天都有人死，”崔广顺说，书记当时就是这么跟他说的。
他本以为孩子要被判死刑了。但北京儿童医院的一位大夫直言不讳：“只要有钱，孩子就能救过来。”他回忆著大夫的话，“如果没钱，就只能等死了。”
除此之外，医院里似乎也没有人指导这对农村夫妇应付异常复杂的程序──甚至当触摸显示屏显示他们每天的花费相当于近一年的收入的时候。“在医院，钱比手纸用的都快。”崔广顺说。
父母根本没法告诉孩子他得了癌症，但小德洁却从同病房的孩子那里得知了真情。
第一阶段化疗持续了一个月。医生们警告说，第二疗程如果被迫中途停止，那时孩子的免疫系统已经被破坏了，很容易就会感染上致命疾病。治疗还是继续下去了，哪怕这对夫妇并不能保证缴纳更多治疗费用。
这些年来，中国的大病救治费用迅速膨胀，已经成了一项沉重的社会负担。崔广顺说，他们村在1996年才通电，大约30多户家庭中一半都背著自身难以承担的贷款，而那些没有贷款的人根本就没有余钱可用。中华全国妇女联合会(All China Women's Federation)在电视台发出呼吁，组织在他家附近地区的捐助，每一次有人身患重病时妇联都这么做。德洁的同学们也拿出了自己的积蓄。还有一次，崔广顺从家里坐长途公共汽车到北京来探望孩子时，司机没有收车费，售票员还组织那趟车的乘客捐款。
医疗成本的沉重压力让越来越多刚脱困的人又迅即落入贫困境地。38岁的崔广顺已经破产了，债务已经超过了他10年的收入，而可以想见，借给他钱的亲戚和邻居的处境也变糟了。
有关医疗费用的种种骇人听闻的事情引起了公众对政府的不满和愤怒。中国国家主席胡锦涛已经承认这是个社会难题，并将改善医疗体系作为构建“和谐社会”的优先内容。
社区卫生服务分会的陈博文正在从事一项弥合遭破坏的社区卫生服务网络的工作。但他说，这项工作需要长达20年的努力才能完成。政府也在积极努力改善医疗保险体系，以便无需完全废除现收现付制。
十一月底的一天，崔广顺最终放弃了──他付不起孩子的所有医疗费。他回到内蒙古的家里，收拾一下空空如也的屋子。他和妻子就是在这里结婚的，现在还有几样他们视为珍宝的物品：一只热水瓶、一台小电视、一套红色的沙发。窗根底下就是一张中国北方传统的热炕。
第二天，他长途跋涉回到北京的医院，和妻子一起站在医生面前，听她指责他们拖欠账单。“一开始就警告过你们，”女医生训著，低头发著短信，根本也不抬头看他们一眼，“现在你们花光了钱，也失去了孩子。”崔广顺低头，盯著自己的脚尖；孩子妈妈默默无语，但眼里充满泪水。
德洁五个疗程的化疗现在正进行到第二阶段中途。本来应该在隔离病房由护士照料，但因为没钱，父母把他接了出来。此后他一直和姨妈住在北京郊外，这使他脆弱的免疫系统面临巨大风险。周末，德洁又著凉了，父亲带他到医院看病，现在在姨妈家中休养。
德洁的父母说，将在一周后把他送回医院，用手中仅余的钱让他完成第二阶段化疗。但是，因为已经办理了出院手续，现在不得不从头排队等待空余病床。
