The healthcare system in China, generally speaking, is quite different than what you are accustomed to unless you were born and raised in a third-world country. This chapter will provide you with an overview of China's healthcare system, especially as it impacts upon Westerners living in the Middle Kingdom from the perspective of medical training, availability of Western medicine, pain management, eye and dental care, as well as how to find mental health services.

Medical Training and Healthcare Delivery
The foundation of Western-based medicine in China can be traced back to 1914 when the philanthropic Rockefeller Foundation established the Peking Union Medical College (PUMC). In 1928, the administration of medical education was split off from the provision of clinical services with the establishment of the China Medical Board (CMB) with the vast majority of its faculty comprising American physicians (Schwarz et al., 2004).

In 1951, with the advent of China's new government, the operations of the CMB were interrupted and would not be restored until 1980. Today, the China Medical Board directly supports medical training and clinical services in 13 hospitals across China, primarily in major cities. From 1965 through 1981, primary healthcare in China was essentially delivered through the brief training (ranging from three to 18 months) of peasant farmers in preventative medicine and in the treatment of common illnesses in what was referred to as the "barefoot doctor" system (Valentine, 2008).

The medical education system in China has undergone vast changes and improvements over the past few years particularly since China's entry into the World Trade Organization in 2001. Nevertheless, medical training in China is still highly variable ranging from a three-year post-secondary certification program to an eight-year program of study leading to the doctor of medicine (MD) degree (available at only two universities), comparable to its Western counterpart. In addition, Traditional Chinese Medicine (TCM) still holds a very important, parallel and separate role to that of Western medicine in China, with the vast majority of locals preferring a combination of both (Moreton, 2004).

The healthcare system in China today is delivered exclusively through a network of government and a few privately owned hospitals: Physicians do not maintain private offices. Whether you have a bad cold or are in need of surgery, you must go to the local hospital to receive medical care. These hospitals, depending on location, range from facilities where you can receive world-class healthcare to relatively dirty, poorly equipped and understaffed structures that far more resemble an old converted boarding house than a modern hospital. As a rule, standard sterilization procedures and hygienic conditions are virtually non-existent and most hospitals, outside the three major and other heavily populated cities, do not even have an autoclave. Depending on location and the hospital, foreigners have reported experiences and results that range from those that are comparable to the best healthcare services available in their respective countries to near-fatal outcomes as well as those involving attempts at overcharging, if not extortion. One foreign teacher, on a popular EFL website, reported that his school was actually in cahoots with the local hospital to perform very expensive and unnecessary surgery.

A good part of the reason for some of these questionable practices is that doctors in China do not enjoy the same social status as do their Western counterparts and they are, relatively speaking, terribly underpaid. A senior physician at a government-owned hospital may earn no more than 3,000 yuan ($435.00) per month, so many rely on kickbacks from drug sales, tests and procedures to supplement their income.

Western Medicine, Chinese Philosophy
Of major concern to foreign healthcare experts is the manner in which antibiotics are prescribed in China. According to one investigative report, Chinese doctors routinely prescribe the wrong antibiotic, and even when the correct antibiotic is prescribed, both the daily dose and the duration of treatment are typically inadequate, which is producing an entire society of antibiotic resistant people (Jia, 2008).

If you ever need an antibiotic in China, do not immediately take it as prescribed. Upon returning home from the hospital, conduct a search on the Internet to confirm that you have been prescribed the correct antibiotic and then determine what the FDA approved daily dose and length of treatment are from the manufacturer's website. Buy additional doses at either a military or university hospital so that you have enough medication to take a complete course of treatment as recommended by the drug manufacturer. Chinese doctors are unwittingly producing a whole society of antibiotic-resistant citizenry and you certainly don't want to become one of their casualties.

Within a week or two of arriving in China, and before you get sick, make it your business to ascertain if there are any Western or Western-trained doctors in your area. Speak to the old-timers at your school or in your city and inquire about any Western-trained Chinese doctors they have had good experiences with. You will probably pay more to see them but it will be well worth the additional investment. Although you could get "lucky" and accidentally find a Chinese-trained doctor who actually knows what he or she is doing, it would be just that—luck, and most of us value our health far more than treating it as if it were a game of chance. All foreign consulates maintain a list of hospitals they recommend for their citizenry, such as the U.S. embassy's page on Health & Medical information for one. In addition, the Chinese government also provides a list of hospitals staffed with English-speaking doctors, organized by province, but it doesn't appear that the list has been updated in quite some time.

Not only the Chinese, in general, but physicians and nurses as well, subscribe to a slew of "medical" beliefs that could best be described as "old wives' tales." For example, a Chinese nurse once informed me that it was "dangerous" for a woman to have sexual intercourse during her menstrual period and that women who were menstruating should not drink or eat very cold substances (she wasn't certain of the reasons but assured me that several Chinese doctors had confirmed this). Most Chinese believe that drinking hot water prevents the common cold or that it is certainly a remedy for most things that ail you. If you show up at the hospital with any type of cold or infection, you are likely to be offered an intravenous solution of saline and an inadequate dose of an antibiotic. Under no circumstances should you ever agree to this I.V. administration: Insist that the doctor give you a prescription for an oral dose of the medication so that you can check it on the Internet to learn the proper dose and course of treatment.

Even if you are relatively young and strong and have little or no history of respiratory and sinus infection, it is highly recommended that you bring at least three to four complete courses of a broad-spectrum antibiotic with you from home: Z-pack (Zithromax or Azithromycin) is a very good choice. Those with known sensitivity to air pollutants should be sure to read the section on Pollution, under the unit Teaching Locations, earlier in this guide. Especially if you will be teaching in the north or northeastern regions of China, it is highly likely that you will acquire some moderate to severe respiratory or sinus infection during your first three months in China.

You should also bring along some Imodium (Loperamide HCl) or some other antidiarrheal medication—you will need it until your system adjusts to the different environment and far greater prevalence of contaminants in the air and food. Public health laws and codes are not routinely or strictly enforced in China and occasional bouts of food poisoning or, more commonly, "the runs" are to be expected. Once you have lived in China for a year or two, your body's natural immune system will eventually adapt to the presence of previously unknown strains of bacteria and viruses that abound here and, then, you will be fine.

Medication Availability
As a rule, all major classifications of drugs are available in mainland China and many drugs that are controlled in the West, such as antihypertensives and antibiotics, can be purchased over the counter here. In less populated provinces and cities, medications not in common use may need to be ordered from a distributor or from another hospital in a different city.

Although, generally speaking, medications are far less expensive in China than they are in Western countries, beware of prices that seem too good to be true. All medications should be purchased at military and large university hospitals only, whenever possible. Avoid buying medications from small unregulated pharmacies as these are often adulterated or completely fake. When shopping in large drug store chains, always buy the most expensive brand available or simply have an interpreter ask the pharmacist which one he or she recommends.

Pain Management
China's history with opioids has been a traumatic one. Owing in great part to the Opium Wars of the 19th century, it is estimated that as many as 20 million Chinese were addicted to opium before the founding of the People's Republic in 1949 (WHO, 1995). Despite the fact that Mao's regime was effective in grossly reducing that number, latest estimates indicate that opium addiction is on the rise in China at an estimated 5 million addicts (Feuerberg, 2010).

The point is that fear of addiction, to the point where it could be diagnosed as a phobia, is an integral part of Chinese culture. Chinese medical students are repeatedly warned about the risk of promoting addiction in their patients and are trained to prescribe non-opiate analgesics almost exclusively.

While China's Ministry of Health officially adopted a Chinese version of the WHO's three step analgesic ladder for the relief of cancer pain in 1995, one recent journal article indicates that there is a great deal of resistance to it in practice (Liu, et al., 2007). Chinese physicians will be both culturally and professionally reticent to prescribe opiate-based pain medications even to patients who are writhing in agony from the terminal stages of cancer.

Consequently, if you require surgery, have fractured a limb, and are either currently in pain or know that the postoperative period will be a very painful one, you will need to be firm and persistent with the doctor about the need for pain medication. If the operation is an elective one (non-emergency), make it abundantly clear that you will not undergo the procedure unless the doctors agree beforehand to prescribe an appropriate amount of postoperative pain killers. If you are firm and persistent, most Chinese physicians will make an exception in the case of their Western patients.

Over-the-counter (OTC) analgesic medications, such as aspirin, are available in China but usually just in very small doses, e.g., 25mg tabs as opposed to the standard 325mg tab available in the West. If you are taking aspirin as a daily maintenance medication for the prevention or treatment of heart disease, then what is available in China will be more than adequate as the recommended dose for this purpose is somewhere between 75 to 85mg per day (basically, one Western "baby aspirin" tablet). If you are accustomed to having aspirin around the house for the treatment of headaches, then you might want to consider bringing along a large bottle of generic, full-strength aspirin with you from home.

Eye Care
Unfortunately, the news is not any better in regard to eye care, barring major international cities. Many foreigners report having had significant problems with their eyeglasses and the correct measuring and manufacturing of progressive lenses seem to be well outside the scope of the present day ability of most Chinese optometrists and ophthalmologists. For this reason, and to reduce costs, many Chinese buy separate pairs of glasses for reading and distance (although many have had relatively good luck with bifocals). Again, you must personally question older foreigners who wear eyeglasses to determine where they recommend you could go to maximize your chances of having success.

Some foreigners have reported acceptable results by going to a large university hospital to be evaluated and measured and then taking their prescription to a large optometry shop for purchasing the frames and having the lenses cut and fitted. As a rule, it will take no less than one week to have a pair of eyeglasses made and returned to you.

Dental Care
Regarding dental care, the news is actually somewhat better as many foreigners have reported favorable experiences, particularly in the three international cities (Beijing, Shanghai and Guangzhou), and it appears that all major cities now have at least one modern "Western dental clinic" where foreigners can be assured of relatively adequate care for less than what the same procedures would cost in the West.

However, please be advised that dentists in mainland China do not use nitrous oxide or general anesthesia. If you need to have a tooth extracted, the procedure will be performed with local anesthetics only, although it has been reported that a few dentists will prescribe preoperative tranquilizers for particularly sensitive patients. Foreigners who routinely require more than just local anesthetics for dental treatment will have to consider Hong Kong, Thailand, or the Philippines as alternative treatment destinations.

Mental Health Services and Psychotropic Medications
A significant social stigma still very much exists in regard to mental illness and mental health services in China. Psychiatry is more or less relegated to the administration of drugs and ECT (electro-convulsive therapy) and clinical psychology, as well as psychotherapeutic services, are still in their infancy here (currently, licensure exists in psychology at the bachelor's degree level only). This is slowly but steadily changing, especially in the major cities and particularly in Shanghai where they now have both a psychoanalytic training institute and a 24/7 crisis hotline.

Foreigners who are living and working in Beijing and Shanghai will, more likely than not, be able to find a Western psychologist or licensed mental health professional offering private outpatient psychotherapy services. To learn of the existence of an English-speaking psychotherapist in your area, you should contact your nearest consulate or embassy.

Virtually all major classifications of psychotropic (psychiatric) medications are available in China. As a rule, if the medication has been in existence for more than 10 years, you won't have any trouble finding it here. It is possible you may have to switch medications within the same classification, for example using Celexa instead of the latest and newest SSRI (selective serotonin reuptake inhibitor), but that usually does not pose any psychiatric complications.

You will, however, have considerable difficulty receiving prescriptions for anxiolytics (minor tranquilizers such as Diazepam) for the same reasons explained above in our discussion of pain management: The fear of inducing addiction in patients is far too great in China. Medical students are trained to avoid prescribing medications associated with increased tolerance, physical dependency, and abuse.

If you are currently taking psychotropic medication as prescribed by a licensed physician, you can ask a family member or friend to send you a supply every month through the mail. The medication will clear Chinese Customs if a Photostat copy of the prescription is included along with the medication and the name on the prescription is identical to the recipient's.