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TB! MEDICAL CilE AND TIEATMEHT OF TB! CRITICALLY-ILL ELDERLY IN CHINA: ISSUES AND LESSONS POR AM!llICAN POLICIES Jolm C. taqenbruuer Prepared for Th Office of Technology Aaae, ... nt u.s. Conare Washington., D.C~ APRIL 1986

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... ACICNOWLEDGMENTS 'l'hia paper would 11ot have been poaaible without the ge11erous time and uaiatance of many 1Dd1vidual1 and orgallizatioua both in the United State and in the People's aepublic of Quna. '!he thoughts and information shared in meetings and discuaaions with them over the last several months can be found in the quotations and citations throughout this tut. There-are also many individuals who, ~bile not referenced in this paper, mu.it be acknowledged for their equally important assistance: Wang Ji, Zhang Bong, and Song Yung Pu, of the Chinese Ministry of Public Bulth; Mra. Wu of the Sban1h&i Municipal Bealth Bureau; Zhong Zhichang of the Cuanad0111 Provincial Health Departmnt; Christopher J. Marut, Della lDox-lemiett, Alfred Bllnderaon, Qiarlea Bennett, and Vincente Tang of the American !abaasy in Beijin1; Bon K. Lee of the American Consulate in Shanghai; bbarta L. Olew of the American Conaulat in Gua111zhou; and Peter Chas of the U.S. State Department in Washington, D.C. Dr. G. Sandra Fischer of the U.S. Admim.stration on ,\sing and Lillian tiu of the U.S. Social Security Adlliniatration provided thoughtful advice and direction in the early atai of this research. Special thanks ~o Judy loaovich for her initiation and direction the Office of Technology Aaaea~nt Project Officer. 'l'hanka, too, for her indpendent reaearch and analy1i11 much of which was aub1equently incorporated into this documut.

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.. It 1 only change tha~ is at work here. -I Ching The Olin love jade. 'l'hat atrange lump of stone with its faintly muddy li1ht, like the cryatalliaed air of the centuries, melting dimly, dully back, deeper and deeper [the Olineae] seem to find in its cloudiness the accumulated aediment of the long Chineae past, and we think how appropriate it 1 that the Oline ahould admire that aurf~ce and that shadow. Tanizaki Junichiro, ID Praise of Shadows (1934) PltOLOGUE Like the aphasia and prediction of its ancient and venerated book, the I Qung, Olina appear to.be in the aidat of great 1ocial and economic change, even tranaforution~ Por nearly a decade, Oline leadership has undertaken and pursued a clarin1 and often paraclozical rour Modernizations" policy-a national effort to update the country's induatry, agriculture, science and technology, .. and def eue. 'lhe unabaahecl 1oal of this elf-proclaimed aecond revolution ia the reahapin1 of the world' moat populoua nation into.a proaperoua and technolo1ically-sophisticated world power. What baa caught the eye of the Western obaerver is not only the pace and zeal of the peaceful yet draaatic shape of events within this country, but also the way in which its goal are being pursued. Living under the dictates of Karl Karz aince the 1949 revolution, led by Mao Tse-Tung, the new system emer1in1 in China either ianores or defies many of the precept most cheriahed by trad~tional Marziata. State ownership has begun to give way to private property, central planning to competitive market, and political dictatorship to limited economic and cultural freedom (Iyer, 198S; Churc~, 1986). Such a turnabout has affected all aspect, of Oiinese life, including its \

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. ,_, :itt .... health care delivry ~ystem. Such a turnabout also has affected its many population groups and subgroups, including its elderly. 'nlis paper focuses on the delivery of care to China's fastest growing age group-the elderly, and in particular to its critically-ill elderly. It emphasizes the utilization of life-sustaining technologies and several accompanying factors-econo111c and financial, legal, aocio-cultural, and religious-that shape not only the delivery system itself, but also the decision to initiate and continue treatment of the country's critically-ill elderiy. While this discussion cannot and will not overlook the current social and economic forces of change, the importance of this recent cultural drama must be viewed in the larger context of Qunese tradition and continuity that stretch back over three to five millenia. There is.little evidence, for example, that the new elements of market capitalism will completely replace the older Marxist approaches. lather, the conscious policy directive is an attempt to coabine or blend these two contrasting and often conflictual approaches. Likewise, the COIIIIIUD.iSt and Maoist-inspired elents of four decades have never fully replaced, but have more often blended with, the many disparate traditions of its pr-ocialist past. :JC111inger (1986) has noted.that such amalgams and balancing acts have been characteristic of the Chineae over time. Ideological shifts go hand in band with the longeat uninterrupted hiatory of self-government. Its cultural uniqueness goes band in hand with an extraordinary variety among it1 region, which are physically separated by vast distances and daunting geographic obstacles. These ethnic andgeographic realities have historically generated an oscillation between a fear of anarchy leading to stifling centralization and a loosening of controls in danger of turning into regional separatism." Jevertheless, the Ou.nese have time and again naged to find a middle ground-an accumulated sediment of culture and 2 -

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spirit. lisainger ha~ characterized it as a rhythm distinctly Chinese. The oscillationa have been, perhaps, tempered by the age-old dictum to, in the words of the Oiinese sage, seek1>alance andharmony in all things" (Lao Tzu, n.d.). _Asainat this backdrop of ~bange within continuity, this paper begins with background di1cuaaion of Quna and its people. For purposes of the Office of Technology Asse1ent report, th~ discussion includes a special focus on the countiy's strong religious and philosophic tradition The Chinese health care system is then briefly described. A discussion of Qlinese customs and policiea toward the aged follows, with anemphasis and review of a nuaber of relevant factors that influence and affect the care of the country' cri tically-!11 elderly. And while the Chinese experience is ar1uably unique in uny waya, thia fact need not preclude leasona and iaplicationa for policies relating to the care of Aaerica'a critically-ill elderly. 'l'he paper conclude with a discuaaion of po11ible benefits for the corresponding American experience. BACGI.OUND Dographic Cbaracteriatica Situated in the eaatern part of Asia, Oiina cover, an immense area of about 3.7 million square rd.lea-just slightly larger than the United States. Population density, however, 1 four times greater in China than in the u.s.1 In fact, Olina is the wo~ld'a moat populous nation, with slightly more than one billion citizens. '!he Olinese count S6 distinct ethnic nationalities among its populace, though approximately 93 percent 1 Ouly seven countries in the world have populations of more than 100 million. Qdna ranks first, and the U.S. ranks fourth (Fisher, 198S). 3 -

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.. ...... .... belong to the largest group, the Ban nationality (MOPB, n.d.). China is administratively divided into 22 provinces, S "autonomous regions (minority populations such as Inner Mong?lia and Tibet), and 3 municipalities (Beijing, Shanghai, and Tianjin) that report directly to the central government in Beijing. 'lhere are also about 2,700 counties, and about 55,000 people's communes. Provinces contain districts composed of counties and smaller cities (Summerfield, 1979). Despite its large land area, China contains vast stretches of mountain and desert, with only a relatively small part being arable. China must feed approximately 20 percent of the world's population with only 8 percent of the world's cultivated land. Quna's population, furthermore, is most unevenly distributed. The vast ujority of people live in eastern China, with its three great river basins. Western Quna, with its mountains and deserts, is exceedingly sparsely populated with less than 5 percent of the population. In addition, fully 80 percent of the Qu.nese people live in rural areas, an almost exact reverse of the population distribution in the UnitedStates. Even within its bordar1, China is recognized as a developing nation eco~~c;ally. A gross national product of $300 per person in 1981 (as compared with $12,820 in the United States) places China in the bottom third of developing nation (World Bank Atlaa, 1983; Bsaio, 1984). Both the urban-rural keup of ita populati~u, and its limited economic capacities have strongly influenced China's policies toward health and medical care. Cllinaae Religion2 The allure of its modernization and new economic policies aside, China 2 Thia discuaaion of Olin religion, unless otherwise noted, is based on diacuaaiona by Capra (1975) and Samagalsky and Buckley (1984). 4 -I

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'. () ,, also must be viewed a, an ancient country. '!he influence of its history is nowhere more evident than in its rich religious and philosophic tradition that continues to permeate the many facets of its culture, including its health care. Chinese religion, like other aspects of Olinese culture, has developed aver a period of more than 3000 years and has absorbed many inf luencea. It has been cbarac terized as a mixture of philosophy, tradition, and superstition, but in the main baa been influenced by three great tre~~s in human thinking: Taoism, ~nfucianism and Buddhism. In their pure forms, each of these is more a philosophy (or way of life) than a .. religion. Tao in. and Confucianism are of ten seen as two complementary traditiona that developed in ancient China to deal with the two kinds of knowlad1e: intuitive and rational, and represented by the Chinese archetypal pair yin and I!!!l which fora the very core of Chin thou1ht. At the same tim~, all three philosoph1e1 have been inextricably interwoven into the fabric of Olineae religious conaciousnesa, and the "popular reli1i011" of the Chinese is beat viewed aa a fusion of ancient superstition w1 th the three philosophies. 'lbe f oundars of these philosophies have all been deified and the Chinese have worshipped both the founders and their disciples. 'Ihe people also have come to worship their own ancestors and a mltiplicity of gods and spirits. Despite the blurring of distinctions between the three philosophies in popular culture, it 1 uaeful here to briefly isolate the aeparate atranda. Individually, each came to occupy a needed philoaophic apace. Taoism taught un to maintain harmony with the un!verae, not to diaturb it. 0>nfucianism, on the other hand, attended to the more practical political and moral aspects of life, and Buddhism took care of the afterlife. TaoiS1D. The concept of.!!!?_ itself is the center of TaoiS1D. Tao is the way of ultimate reality, the basic mystery of lif-it cannot he perceived 5 -. \J

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.. ...... because it exceeds t~e senses, all thoughts and all imagination. It can be known only through mystical insight, which cannot be expressed with words. Tao also is the way of the universe, "the driving power in nature, the order behind all life, the spirit which cannot be exhausted. For the masses, the power of the universe was often the power of gods, magic, and sorcery. And Tao refers to the way man should order his life to keep-it in line with the natural order of the universe 'nle Taoists rejected self-assertiveness, competition, and ambition. They revered humility and selflessness, and were disinterested in the things the world prizes like rank and material goods. Nature was an entity to be made fr.iends with, rather than conquered, dominated, or ccuttrolled-the idea being to blend harmoniously with the Tao which flows through everything. Civilization tended to be condemned and simplicity encouraged. Confucianism. While the Tao is perceived as running through everything, Confucianism focuses on man. And with the exception of Mao, the one name which has become synonymous wit,h China_ is Confucius. Born only a few years after Lao Tzu (the founder of Taoism) around 551 B.C., the ideas of Confucius permeated every level of Olinese society within a few. genetaciona: government offices-presupposed a knowledge of the Confucian classics, and spoken proverbs trickled down to the illiterate masses. Living during a period of great social conflict, Confucius sought to find a way which would allow people to live together peacefully. For Confucius, the answer waa derived from selected traditions, handed down from generation to generation; if the continuity were ruptured, then the society broke down. Confucius also further devised what he thought were the values neceasa~ for the collective well-being. 'nlese included not only the building of ideal relationships between humans, but also a knowledge of how to behave in a given situation, a set of manners. Behind these concepts is 6 { l;

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n 1'\ 6. 0 .... the presumption that the various roles and relationships of life have been clearly defined. In the Confucian system of things there are five main relationships: father-eon, elder brother-younger brother, husband-wife, elder friend-junior friend, and ruler-eubject. What one does affects others, each ia never alone when acting; one's actions must not damage or create conflict with other individuals. Confucius reinforced the pre-existing Olinese notion of the family as the.basic unit of society. 'l'he key to family order is children's respect for and duty towards their parents-filial piety or .. ~-Also embedded in this concept is respect for age, which gives everything-people, objects, institutions-their value, dignity, and worth. the old, while at their wuke1t physically, are at the peak of their wisdom, knowledge, and experience. leapect flon upwards, from young to old. Laatly, ~nfuciu rejected the uae of force and even the uotion of a riaid code of law. Conduct could not be enforced by some organization set up for that purpoae. Taking legal action also implied an incapacity to work thin11 out by sensible comprOllliae and neaotiation advocated by Confucius. Buddhi. Buddhism is aore of a philosophy and code of morality than a ~ell1lo~_because it is not cent,red QD a god. lather, Buddha rejected the supernatural. Buddha tauaht that all life is auffering, that everyone i1 subjected to tba trauu of birth, to sickneaa, to decrepitude, and to death. In Buddhism, the belief la that one 11 alway tied to what one abhors (e.g., an incurable diaease or personal weaknes1), and ia separated from what one loves. Real happiness cannot be achieved until suffering is overcome. The cauae of happiness is tanha-or desire--specifically, the desires of the body and the desire for personal fulfillment. Happiness can only be achieved if those desires are overcome. 'Du.a requires following the 7 -

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..... ~ "eight-fold path".of _the right: knowledge, aspirations, speech, behavior, livelihood, effort, mindfulness and absorption. The right absorption involves the techniques of Hinduism's I.21!., a discipline designed to teach control over all the functiou of the body. Buddha also accepted the Hindu concept of reincarnation, the cycl of rebirths, and karma, the law of cause and effect. Contaporary 1.eliaion, Culture, and Communism. Besides Taoim, ConfucianiAL, and Buddhin, other religions at one time or another in various places around the country took root and continue to thrive as well. these include Islam, Olriatianity, even .lldaism. Preaently, the Olin govenuaent profesaes atheism, and considers reli1ion and superstition a tool of ruling classes to keep power and privileae, and an archaic remnant of old China. Oliu's public policies are, of course, stronaly influenced by the newer political and economic philosophy of Communin. In brief, Comunin prof that the means of production (factorie1, land) be owned by the. people collectively, rather than privately, and espouses policies that benefit society as a whole rather than individuals. Ideally, each individual is to receive accor~ing to bi1/her_need. Typically,.centrally planned and governed economies are created to transform this philosophy into practice. Still, freedoa of traditional religion is guaranteed under the Chinese coutitution, and over the last few years there baa been a resurgence in active, organized religion in Olina. At soae places, the monks and priests, driven from tmples and monasteries during the Cliltural Revolution, have been allowed to return. Other temples have even been renovated and are of ten attracting many worshippers, in large part~ the elderly (Zhong, 1986). -a.. ')

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'rBE CHINESE BJW.Tll CARI SYSTEM Health Policiea By all account, Olina bas given high priority to public health and dical_care aince the founding of the People' Republic in 1949. Before 1949, Olin.a' population auffared a crippling burden of diaeaae and r: _; _-.. J '1: pr-ture death. Periodic epidemics of plague, cholera, -11poz, etc. swept ~e land which-combined with frequent famine-sometimes decimated entire populations. '.the epidemics were superimposed on a high underlying level of aorbidity and 110rtality that continued into 1949. Such occurrences urned pre-Maoist Ouna a reputation as the sick u11 of Asia" and led to low level of life apectancy 1enerally believed to be le than 35 years (World Bank, 1985). Such a atate of health reflected a century of political factionali and aocial upheaval, 1111ch of it cauaad bJ foreign traders and foreign and.ea as Ouna be1an to open ita urket to the world. Por the first three decacle of the nn aocialiat reaiae, Olineae development effort maphaaized two main objectivea--development of a heavy induatrial and eliaination of the worat aapects of poverty. An iaportant part of the. aubaequent anti-poverty struggle was to undertake basic public health meaauru and--relative to other countriea-to develop natioul policies that eaphaaized public preventive over curative health aervicu for the tuk of controlling c01111Unicable diaeaaes. Ezperiments in aeetina basic health needs were atarted during the 1930. and 1940. by Kao and the People's Liberation Army while encamped in various provinces. Tnese efforts involved mobilizing the people to educate themselves and encouraging th individually and collectively to provide their own health care and dical care services (Sidel & Sidel, 1974). 'lhese experiences generated an -9-

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..... -~ interest in health especially related to rural areas and peasants.3 Major campaigns were mounted under a strong central policy shortly after 1949 to improve environmental sanitation; to.eliminate the four pests--rats, flies, ao1quitoa1 and bedbugs; to vaccinate aaainst and cure infectious d11u1as; and to control the major endemic disorders such as malaria. Mass mobilization played a key role in the success of these campaigns (see, for aariple, Sidel and Sidel, 1974; and Ma Bai De, 1985). These vigorous prevention efforts, according to a recent World Bank report (1985), were undoubtedly enormously successful in reducing morbidity and mortality." But Olina's overall emphasis on prevention policy also led to pursuit of a hult.h 1trata11 that reached well beyond the health system per se. In particular, improved D~trition, provision of safe water supplies, sanitary and convenient means of waste disposal, fertility reduction, and widespread educatioual improvements have.been major policy objectives. Again, the recent World Bank's report (1985) concluded that the multi-faceted strategy baa been a success, thanks laqely to the 1tron1 and centralized "adainistrative capacity and political will of the Olinese government. the historical emphasis on public preventive measures, bowe!er, has not beaa:\lnde~taken while neglecting the illportaace of curative health measures for the vell-beiq of the population. ID fact, the allocation of health ruou.rcas to preventive activities generated a daand for at lust minimal curative services and pharmaceutical availability in even the more remote rural areas. through 1982, health care facilities for curative services had increased by more than 50 times the 1949 levels. Hospital beds had increased 25-fold, and health professionals had increased by nearly 7-fold, 3 the farmers and people of the Chinese countryside engaged in agrarian pursuits are popularly referred to a peasants"; -10 -

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,. including about 2.7 t~e the nwaber of physicians as were practicing in 1949 (MOPB, no date). ') 1--_, 1) ;._ Public health and preventive measures, combined with curative services, have Mt with 1ub1tantial 1uccess as evidenced by change in mortality and morbidity 1tati1tic1. Average life expectancy bas increased drautically-fr011 about 32 years in 19S0 to 69 year, in 1982, which is only about ah year, leas than in Western market illduatralized economies. In addition, success.baa resulted in the emergence of new leading causes of aorbidity and mortality. In urban and much of rural China, parasitic and infectiou1 di1uaes causes of death have been 1ub1tantially replaced by heart disease, cancer, stroke, cerebro-va1cular disuse, accident,, and chronic respirator,' di1uses. Por aaapl, th aortality rate for cerebro-vascular di1use aore tban doubled between 1959 and 1979 (Wu tina-E'ai, 1985; Zhou Guanboq, 1985; Li Pei-tiong and Li Olona-an, 198S). Infants, children, and young VOIND have been supplanted by the aiddle-aged and elderly a1 the population groups with hiahest 110rtality. 'lbe older age aroup also are cousuaing an incrusing proportion of medical care, in large part due to incruaing aaount1 of curative therapies for these increasing probleaa of chronic diseases (World Bank, 198S). 'lbis shift in diauae incidence and prevalence, which baa already occurred in industrialized countries, ia c01111only referred to as the epidaiolo11c trauition. Urban Oline diaeaM patterna are increasingly parallel to those in high incOIIN countries, and a aiailar trauition 11 proaresaing in rural Oun.a a, vell. Still, liaited econoaic capacities have not allowed.Olina to reach parity with the Weit in health personnel and facilities. For example, in 1982 Oun.a had 2.03 hoapital beds per 11>00 people (as coapared with 4.5 per 1000 in the United States). there are 588,000 senior doctors trained in Weatrn Mdicine and 513,000 senior 11 -

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..... .:w.. doctors trained i~ traditional medicine (discussed in more detail below), yielding a ratio of about l senior doctor per 1000 people--about half the U.S. ratio. the historic shortage of highly-trained doctors plus the national aapbaai1 on prevention has led to a resulting sy~tem of greater reliance on the uae of indigenous paramedics and other auxiliary personnel to carry out baaic educational, preventive, epidemiological tasks, and simple curative vork. China, for example, has 445,000 assistant doctors trained in Western medicine who have had two yea~s of medical education beyond junior high school (Statistical Yearbook of China, 1983; AB.A, 1982). Most of the primary hulth care in Ou.na is provided by paramedics called village doctors,~ who usually are graduates of pr1mary schools with up to six months of training in public health and primary care. According to Bsaio (1984), there are currently about 1.2 million of these paramedics in China. Aa the basics of hygiene and co11111111nity involvement in preventive health becoae more established, however, it will become necessary to upgrade their skills to undertake more specialized care. 'lbe Qlinese in fact plan to upgrade SO to 60 percent of its village doctors to the level of assistant doctor within the decade. Likewise, the increasing prevalence of chronic clisaa1es, which places greater deunds on the upper and of the system of health care workers, baa led to more intensive training and education for 18111or doctor1-including a greater mpba1i1 on the u1e of Veateru technology (Dobson, 1981; World Bank, 198S; Fox, 1984). Sidel (1982) has already noted the decline of village doctors by roughly 22 percent between 1978 and 1982. 4 ID the past, these village doctors have been popularly referred to 111 the Vest a1 ,arefoot'doctor1, though the term is no longer form.ally uaed. -12 -

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. Daer alo 1 fairly videpread evidence (Blladeraon and Cohen, 1982; () j". ;: v ,_! Pox, 1984; World lank, 1985; llllaio, 1984) that hopital beda, health peronnl, and other health reourcea are unevenly ditributed between the urban ad rural arua. In 1980, the avera1 nuaber of bed per 1000 people aore than twice the a.uaber in urban areaa, with the distribution of aenior doctor even aore uneven: 2.4 per 1000 people in urban areas and O.S per 1000 in rural areas. The .. Planning Process Health policy in Olina ia directed by the leader, of the Party and is refined and planned in detail by variou1 levels of an ateuive bureaucracy headed by the Ministry of Public Health (NOPB). It extends down to all administrative divi1iona. Dobaon (1981) baa noted that in this sense the Olineae planning systea is auch like that of the U.S., in that a aulti-levelecl government structure is called upon to resolve and implent natiOD&l health care policy (e.g., the Medicaid prograa). 'lbe provincial level bureaucracy is a key planniq a1ent that revises district, county, and municipal applicationa for reaources. Provincial autho~itiea can authorize.11.aited capital-coutruction (such as remodeling a boapital), de1ign health prevention caapaipa, traufer and place medical per1onnel within the province, and act in ca1es of large-scale dical ... rgenci (In uch cae, the HOPI uy be called upon for extra budget assistance.) Provincial Party cOlllllitt~ea review the.work of the provincial bureaus on policy'iesues and reour~e allocation. Below the provincial level_, uny health care delivery activities are locally naged at the aunicipal and cl11trict level. Because each jurid~ction ha input to ~he planniq and delivery-~roce, goals which at firt appear unifora at the national level aaybe quite varied in 13 -

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application. ....... ~ 'l'be Miniatry of Public Health controls the money for capital coutruction and purchases of major pieces of equipaent and technology. Punda flow from the Ministry through the province, to diatricta, municipalities, and counties. Resource allocation plans are revised as they are paaaed up through the hierarchical structure. The Olinese planning ayat, then, might be termed a top down-bottoa up process. lhe allocation of funds is determined by need, changes in population, industrial development, etc. 'l'hua, developing areas may receive disproportionately more funding (Dobson, 1981). The MOPB also directly manages a major hospital, vaccine production facilities, the core medical colleges, and medical reaearch institutes (World Bank, 1985). I Overa~l, th~ugh, th~ MOPB is organized to set general policy only. Power is being increasingly decentralized under the government's new econollic policy. this is a marked departure froa the 1960. when health policywaa centrally formulated under the influence of a limited number of Party members, bypassing the medical establishment and technical planners. 'J.'he Organization of Care Por the O\inese, health care la one of the five guarantees, and despite reaource lillitationa, ia oqanizatioaally available to all. Chinese health peraoanel, health station, and ho1pitala are organized throughout the nation on a three-tier system of service characterized by increasing c011plexity and specialization; this 1y1tem varies in urban versus rural locationa. In rural areas, the first tier comprises barefoot doctors, who provide both preventive and prima-ry-care services. Before 1980, an averag~ of two barefoot doctor (moat of whom were alao engaged in farming) served 1000 14 '; ..

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.. () -people. ror aore aerloua lllneaau, barefoot doctor refer patient to the aecoad tier: coamua health centers, which may have 10 to 30 bed each, and outpatient clinics, each serving 10,000 to 30,000 people. At the c01111Une health ca11tera, tha aoat qualified medical workers are aaalatant doctor,. Finally, the aoat aerioualy ill patients are referred by the ~ommune health center to the third tier: county hospitals. Each serves 200,000 to 600,000 people and is ataffed with senior doctors who 1raduated frOII a five-year medical.school after completing high school. In rare cases, the patient uy be referred to a specialized ( tert:1.ary) hospital. In urban area, the first tier couists of paramedic working in factoriea and in neiahborhood aed Cross stationa, where basic primary care ia provided. More aerioua case are referred to the district hospitals, and the moat aerioua are referred to municipal hospitals (Baaio, 1984). Side by aide with the uatvork of national, provincial, and local facilities which aerve the entire population, there~a network of industrial and other state enterprise hospital a well a other facilities that provide free services to workers in thoae enterprises. In 1981, they provided about 25 percent of Mdical care in Ouna. Depencliq on the size of tlae enterprise, complicated_ cases are treated in their respective health facilities, or referred to the govermental hospital Yt. Large mterpriaes handle alaoat all their ovn ca and the Railway Ministry and Array, to take atr aaaplea, even ~ve their on. aedical colleges as well as hospitals (World Bank, 1985). For post-hospital care, there are fn nursing hoaea at present, but additional hoaea are being planata4. '!bey are adainlatered by district hospital (Lee, 1985), and each pref~ture baa at least one, thou1h it uy aene other .functiou a well (Shou Sbaq Jue, 1985). Ible-care proar were beaun over two decade ago a. solution to the bed 15 -

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....... .:'IP. abortaa (Meng 1 1, 8S )_, but 1,ecauae home care_ 1 provided by bopi tal personnel, it la-available 1enerally only in large cities where it is undertaken by the larger hoapitala. tt is a program which the Ministry of Public Bealtb favors, though, and currently it is growing at a substantial rate (Wu Yuanjin, 1985). At first glance, Olina' patient referral system appears well-organized. Given the relative scarcity of facilities and personnel, criteria for increasingly specialized care sho~ld be well-defined to allow improved and more appropriate access to more sophisti~ated settings. Henderson and Cohen (1982), however, notethat a nuaber of factor other than st"rictly dical ones have produced uneven pattarna of which patients receive second and third-level care. For exaple, geographic and occupational characteristics are strongly related to adaiasion at tertiary care facilities. Moat of the patients adlllitted were urban workers .and urban and rural cactreacgoverment officials), rather than peuanta. ID addition, rural patients who ultimately gained adaiaaion were generally sicker than urban counterparts. Handerson and Cohen attribute differential patterns of use by urban/rural residents in part to ease of travel and differing.level of .perception or aophistiction of medical.care need. 'lbree time as many urban and govermaent work.era were found to deviate from non-standard referral route in the pursuit of more specialized care. Because access to goods (auch aa specialized medical care) ia often limited, many Olineae are still very auch reliant on non-standard approaches, inatitutionalized privilege ayateu, and personal connection (guamd) to aupply tha with goods and service couidered acar~e. Lastly, Benderaon and Cohen attributed differential pattern of use to atem f r011 very different levele of lu~rance coverage that aiat in Quna--diacuaaed in mre detail below. -16 -

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;.: Pina11eina C&re OVerall, obeervers agree that policies have reduced financial barriers to health care 1ince the 1949 revolution (Prescott and Jamison, J984). 1o .. ver, there baa never been any'public proviaioa for a centralized -utiooal health i~urance ayat. At it1 aiapleat, health insurance ,. coverap for patient, in China can be aaid to vary by occupation, and (again) there are ujor differences between urban and rural ,ru.a with respect to health.care financing While preventive and public health programs are almost totally financed by tba central aovernment, it pays oiy 20 to 25 percent of medical services (Chm11 1982). A.a previously diacuaaed, govermaent fund go prillarily to absorbing capital coat for hospital and c01111Une health center,, staff ularie1 in th iutitutiou, and any deficit, includiq unpaid bills of patient,. Operating coat are uaually borne by the local cooperative health care fiunciq Jt-. '1'hi1 auna that patient auat pay for primary care, the coat of 1upplie1 and maintaunce of hoapital1 and health centers, and drup (whichaccount for upward of half of health coats) (Baaio, 1984; Dobson, 1981). : _-IDu1:auce coverage ia de~igned. to co!r. the patients' coats. In the urban area where aoat of the people are ployed by the aovernment, allitary, or atate enterprise, health iuurance ruervea are created and paid for by ployera. 'lb worker typically have received complete health care coverage package and partial coverage for dependents, financed throqh funds set aaide for that apreaa purpose (Prescott & Jamison~ 1984; Liu, 1983). ID the rural areas, health insurance has been organized and financed throuah a cooperative medical inaurance ayat, with money pooled from individual local collective welfare funda and individual aonthly premium -17 -

PAGE 20

....... -~ .... contributions. 5 In r_eturn, members (peasants) and their families receive free care," but coverage varies rather dramatically: from 40 percent to 100 percent, depending upon the wealth of the collective--which depends to a 1raat dul on the output of production. Cataatrophic care, for example, is frequently not offered by the poorer communes. Health care financing practice, then, are not typically desigued to devote large amounts of ruources to aave a very few persons (Dobson, 1981; Bsaio, 1984). Under the recent economic reforms, self-reliance is emphasized and peasants now receive direct rewards for individual output This has pushed up production but hurt the collective welfare system as.almost 80 percent of the briaadea have shifted from collective to household-baaed production ayatems. 'l'he proportion of the rural population protected by the collective aystem has dropped from90 to between 40 and 45 percent (Hsiao, 1984). As a result, many of the formerly salaried vi~lage doctors ployed by the collectives now minister private fee-for-service practices to a graving 1roup of 1elf-inaured patientle. For the healthy rural population, the loss of the cooperative iuurance reimbursement system has not been a problem. Bowever, tho people ~th serious illnesaes have either been h~avily hurdened~by this out-of-pocket system, or correspondingly, facilities and doctors have accuaulatecl large debts. At the aaae time, aa previously -mentioned, the Chinese public-financing 5 'l'b rural cooperative ayatea was developed in the 1950a after the collectivization and atate takeover of the laud. Peasants were organized into production teas (100 to 200 people each, corresponding to one or more natural villages), work brigades (averaging 1,000 people uch), and commune (avera1in116,000 people each). Under this system, village doctors, like the peasants who worked on the land, received a certain nuaber of workpointa for each working day. At the end of the year, output and profits were pooled at the brigade level, with a portion set aside for a "welfare fund which financed a large portion of the coat of health insurance (Hsiao, 1984). -18 -, . __ :,

PAGE 21

; :: ... J ., ._, i,." -~' ':i: 1y1t baa been furth~r decentralized. Each province or county baa become increasingly responsible for the taxing and provision of health and social 1ervice1, including the payment of bad debts. To what extent the new nforaa at the individual and provincial level will further accentuate type and availability of care between prosperous and poor, havea and have nots, naalu to be aeen The Practice of Medicine: Traditional and Western Approaches there are two distinct 1treaas of medicine in China-"traditional" aedicine and "Ve1tern" medicine~ Until the seventeenth century, the history of dlcine in Olina waa 1ynon011ou1 with the history of traditional uclicine; external influence, and invaaiou of foreiper1 were often abaorbed and traD111itted into the Qdne1e way of thinkiq. atineae traditional medicine 11 probably the world' olde1t body of clical knowledge, haviq a hi1tory of 1everal thousand year of accumulated pirical ob1ervatiou and ab1truee and coapla theory. By virtue of its rich and ancient theoretical ba1e, Chine traditional dlcine, which incorporate, both diapo1i1 and therapy, differ from many other 1yst of folk-aedlcine which are baaed purely on empirical observation1. Diagnosis requires data that are quite different frOlli thoae gathered by Veatern cloctora, however. Diapoatic 11ethod1 include obaervatione and questioning of the patient, ancl detailed and prolonged palpation of the pulse. Diapoais al10 may include observation of the patient' temperament, odor, and tongue. Therapy makes use of medicinal herbs, mozi buatioa., breathlq and gymastic exercises, and acupuncture. The theoretical concepts of health and disease are based for the most part on a philosophic explanation of nature, on a belief of the unity of man and the universe. It was felt that the hU11an body was constantly influenced -19 -

PAGE 22

.... ...... ... by tha coaplementary forces of yin and I!Y. and that if all of the forces were in perfect order and harmony, the human body would be in good health. The traditional me~icine that has flourished in China, thouah, has also led to a wealth of empirical observations. Among them is said to be the discovery of the circulation of blood 2000 years before its discovery in the West (Sidel and Sidel, 1983). With the advent of the socialist regime in 1949, a decision was made to emphasize the traditional medic~ne approach. this was a policy rooted as much in practicality as in theory, though. China had few practitioners of Western medicine, and consequently, was much more reliant on the use of traditional medicine. Th considerable suspicion of Wesr.ern-~rained phyaiciana and intellectuals which existed during the 1950s further damaged I the i~luence and use of Western methods (Dobson, :1981). While the number of.Western medicine physicians is now greater than their traditional medicine counterparts, official Chinese policy in more recent yura has been to encoura1e and develop through education and research not two but three atru.u of aedicine: traditional, Western, and an integrated approach. tlu.s intearated approach is intended to b~rrow the most:clinically effective therapies from ~0th-traditions to the medical and aconoaic advantase of all (Lee, 1986; Zhong, 1986). Today, Chinese practitioners replarly integrate the two fonaa of medicine. Traditional phyiciana, on averaae, u about 70 percent traditional and about 30 percent Western medicine. Western practitioners reflect similar weights but in the opposite direction. A course of treatment ver, easily could be initiated in one mode and changed to the other, depending on the circumstances. Similarly, the same patient might receive both traditional and Western.medicine for co-existing conditions. In some inatances, the treatment itself might represent~ coabination of traditional and Western 20 -

PAGE 23

' practice (Zhong, 19~6; Dobson, 1981). r. .. .,,...: .,-, \.. j :._') 'l'be decision to apply traditional or Western medicine 1 ude on a caae-by-caae baaia. '!be phya:lcian ultimately decide, but patient do have influence through the intlal choice of provider (Wang, 1986). there 1 aoae evidence, too, that that the elderly generally prefer traditional approaches (Zhong, 1986; Weddle, 198S). Weatern medicine, though, is reportedly used in aoat cases of cancers where aurgery is indicated and for coronary conditions (Dobson, 1981) The use of herbal aedicinea is integral to traditional medicine. Herbal aedicine is frequently in evidence in c01111Une clinics, hospital setting, and in town shops. Varietie of herbal medicines are often stored side by aide in rack, to be ground freah for uae orally or to be prepared for injection. In hospital and clinic aettinga, herbal aedicinea are alao atored in close proxillity to Weatern dicinea. Herbal medicines have been reported in Western literature aa effective agaiut cancers and blood disorders (Macek, 1984), diahetea, h-plegia, tuaora, (Bandel and Ling-Ling, 1983; Jain, 1973) pulaoaary diaordera (Hyatt and Feldaan, 1978), iaaunological iabalancea (Macek, 1984), and manageaent of burn patients tShl~Ti~Siang, 1983). 'l'bere_ia alao evidence that these medicines often produce fewer aide effct than comparable Western pbanaaceuticala, and are aoaetiaea useful in alleviating aide effect of Western drug therapiea auch u cbeaotherapy (Macek, 1984). Acupuncture techniques are perhaps even aore integral to Olineae traditional dicina. '!be traditio~ dical schools emphasize the use of acupuncture for nuaer':18 ailaen.ta and for aneathesia;weatern acboola alao train atudents in ita teclmiquea. 'lbere :la little in Weateril literature : <-, for exaaple, Gaw, et _al., 197S) tbat d~outrates th~ effectiveness ~f thia technique-. However, Qdne practitioners claia a wide range of -21 -

PAGE 24

.... .. ... ........ treatment posaibiJit~es, including treatment of neurological diseases, diaeaaes of the digestive system, infections, acute dysentery, appendicitis, coronary heart disease, intestinal infection, diseases of the respiratory ayatea, aathu, aller1ies, chronic sinus ailments, diseases of the joints and muscles, mental illness, and shock. Acupuncture is claimed to be particularly useful in pain reduction, reduction of paralysis, and stroke recovery (Sidel and Sidel, 1974; Bischo, 1974; Tan Aiquing, 1979; Dobson, 1981; Meng, 1982). Snow (1971) states that acupuncture treatment is best suited to diseases of the nervous syst. Acupuncture anesthesia has also been reported by Dobson (1981) as the preferred approach in 30 percent of surgical procedures. Utilization Patterns for Services and Procedures What emerges in this discussion of the Olineae health care system is a pic;ure of tremendous strides in iaprovin1 the public's health over the la&t three-and-a-half decades. Its approaches to iaproviq health, and its relating succcesses, have influenced the thinking of health care providers and professionals the world over In e1sence, large-acale and sustained efforts in environmental illproveaent combined with preventive aedical measures (e.g., health caapaigna) have 1reatly reduced the incidence of c011111Unicable disease in aoat of the coUDtry. Diffused illproveaenta in basic curative medicine also have 1reatly reduced mortality rates from the acute illnesses that have recurred (World BanK, 198S). Such p~ogreaa largely has be~n accomplished by ~tilizing a labor-intenaive and low capital-intensive approach to health and medicine. Medical technology and associated styles of practice, until recently, have beea notably abaent. In the rural areaa;sanitation1 iaunization and -22 -

PAGE 25

, (\ .. ,. ,.--. I; '-.. -. L~ vaccination prograu ~ve been dOllinant. At county hospitals, the level of technological sophistication baa been evidenced typically by operating room facilities, as well as x-ray and laboratory facilities (Olen and Tuan, 1983). Only in the urban areaa, at the aecond-and third-level tiers in the dical syat, have device and capital-inteuive technologies and services been available. At the jor mnicipal and apecialty hospitals, aa well as tbe boapitala aaaociated with Mdical schools, an array of equipment and technology can be.found. Thia is important in that it iapliea a very different a1x of services and procedures for the elderly in China compared to the United States, especially the critically 111. Still, there is very llllited-evidence and data on avail.able aervicu for the critically and While reliable statistics on national utilization patterns are unavailable, the aiatence of intemive care unit (ICU) and coronary care ualta (CCUa) 1 fairly well-tabliahed in the laqer urban hoapitals in auu. Such facilitiea typically have lltG bedside monitor, ventilator,, blood ga1 analyzer,, and 10 on ( Gao Li, 1985). Many alao have 1ophlsticated auqical um.ta and poat-euqical recovery um.ta (Owig, 1983). Organ t_r_!!!!plan~~~ion cent~z:~~ ~or aaaple, recently have been eatablished at Mdical centers in Wuhan (lerkl, 1986). Ucluy transplant center alao bave been reported in ujor urban areas. ID leijiq, for exaaple, 300 trauplnta have beeD pertorud over the last two years. Donora are often faaily bera (Wu tuanj1n, 1985).6 Udney dialyai1 centers in hospitals and a liaited utilization of continuous mabulatory peritoneal dialysis (CAPD) also bas been reported (Chiang, 6 Oqan donora are often family meabera rather than cadavers because Confucian teaching does not allow the dead body to be disturbed. It 1111st be returned to the ancestors. 23 -

PAGE 26

-.. -.. .. 1983). Ro data a;e available on utilization of transplant procedures or dialysis by age, however. Ventilation and respiratory equipment also are common in larger urban and 1peci<y hoapitala (Mena, 1986; Quang, 1983; Lee, 1986). the availability of MA-1 respirators and defribillators, for example, is made poasible for both eraency ad1d.saiona and the inpatient criticall:,-ill (Chian1, 1983; Meng, 1986; Li, 1986; Lo, 1986; Zhong, 1986; Vang Zan Shun, 1986; Zhou Guanhong, 1986). Nutritional therapies and antibiotics, on the other hand, are considered baaic in Cllina and enjoy widespread use. Taylor and Xu (1986), for example, report tut oral rehydration bas been used widely in both urban and rural areas for over two decades. Nutritional therapies, too, have been aaphaaized as baaic pu.bllc health and preventive aeasuru for both the young and the elderly. Greater production of food as well as higher levels of protein-enriched foods have alleviated uny of the nutritional deficiencies of the.past (World Bank, 1985). Nutritional fad are not uncommon, such as the use of herbal m.edicinea intended to increase strength or to prevent a1iq. Enteral tube feedina and parenteral nutrition aenerally_are available at secondand third-tier level facilities (Be Bllide, 198S; Meng, 1985; iabuqer, 1984). One obaener bas noted, however, that uutrition ad 1111trittona1tber-pie1 ara not be:tngpbasized adequately in China' dical education proarau (ilaiaburger, 1984). Antibiotics and drug production generally have been extrely important 1ince the. beginning of the 1ocialiat re11M, again in conjunction with China' preventiOll policies (Wang Zan-Shun and Zhou Guanhong, 1986). Drug production is laqely 1tate-c:ontrolled and is growing at the present rate of 6 to 7 percent per year. Current production is 14 times greater than in 1957. In recent years there baa been a very rapid increase in the 24 -

PAGE 27

. 'l production of dru1 for the trutaant of tuaors and cardiovascular disease. Further, new antibiotics are being introduced in place of the old (World lank, 1985) ---. /" u:.. Por the future, there are atroq indicatiOIUI that Oliu. uy increasingly 110Ye cloaer to the hiahly capital-inteuive medicine of the Vest. '!here alrudy 1 aoae evidence of auch aovmt. At luat half a dozen CT acmmen have been repoited available in each of the aunicipallties of Beijiq, Shanghai, and Guangzhou, for aaaple (Teng, 1986; Zhou, 1986; Wang, 1986; Z~ong. 1986) Medical school have emphasized technology utilization in the curricula, and a rapidly incrusiq DU11ber of aedical students are receiviq trailliq 1D the W.at. 1lov prudent auch a policy push uy be bas bN1l quutionacl, hONver, becauae of continued econoaic coutraints and the Uaitacl ffid~ce of piu ill averap life expectancy in th.e Vut froa the utilization of apeuive, t~clmoloa-apecific practice stylu of aedicine (World Bank, 1985). '1111 ClllRESE ILDDLY: IIIAL'l'B ARD VIUA&E POLICIES Secial Wal.fare Proviaiou Accordiq to the 1953 ceuua in China, there ware 64 aillion men over iztJ and .,..11 over fifty. ly 1985, accorcllq to World Bank fiprea, the maber of ad over the ap of fifty bad ra.a1hl1 tripled to juat under 200 aillion (see fipre). 'lhat 111111ber 1 apected to triple a1&111-to 600 ailllon-over the next 50 year~ tenaa of percentages, the Cbinese Ratioaal Collllittee 011 qing (Wang Gongshi, 1986) estimate that about 8 percent of the current population is over 60 years old, but by the end of this century the proportion of the nation' elderlr will have increaaed to 13 25 -

PAGE 28

.. : ....... c: .. 0 1'10 .. .. ... ...... CHINA: Projected Populatlon owr 50 Years of >gs. 1980 2030 1995 Veer Source: .. World Bank ( 198S) I' --..... "2CZ:5 2C30

PAGE 29

' ;:; percent. Such 1rovt~ in the population of thi age 1roup in Western illduatrialized econom.ea ha certainly been the norm, not the exception; but for China it represent a new phenomenon, and policies affecting the elderly are lncruaiqly iaportant and visible. Since the advent of the aocialiat regime, Ouna' elderly have typically bad two level of npport: the fudly and iuurance (or peuion) beufita. ror the 1rut jorit7 of .the elderly, care and treatment ia in~ricably bound up with the.family. The traditional importance of the family--and the correeponding reepect for the elderly members-are legendary. Dominated by Confucian thou1ht1 Oline aociety baa alway, pbaaized the aipificance of cloH faaily and kiuhip ties. Traditionally, family relatiouhipa have provided the individual with not only otional 1ecurity and a 1enae of beloqina but alao ecollOllic, poll ti_cal, and 1ocial auppor~. Family became the ba1i1 of aovermaat, and corrupondiqly, uaad uny of it functiou, auch education, diapute Httl-nta, poor relief, and aupport for the a1ecl (Wu taunjin, 1985; Dixon, 1979). Since the 1949 revolution, the role of the family baa been downplayed at variou1 ti in an effort to 1tren1then and prioritize commitment to the atate and collective. During the early 19.501, and again during the "Great Lp rorward" of the late 1950, policies were developed to encourage Nparation of elderl7 fr their fud.lie1. Since the 1950., however, priae reapouibility for the welfare of the elderly baa rmaained with the family. ~rrt coutitution and aarria1 law in fact require that children provide for their parente. Typicall7, aged parents live With one of their married children, receivina econOlllic 1upport-while helpiq with child care and houaehold task (Wu Yaunjin, 1985; Dixon, 1979). A 1econd level of 1upp~rt for the elderly worker is uaually a retirement peuion paid out o~ labor iuurance pro1rama; the rural peasant alao ia -~-

PAGE 30

"''"' -~ ... provided a guaran~ to the baaic n~cessities of life and a funeral. For both pensioners and the rural peasant, continued medical care coverage is provided, as part of an overall benefit package. Elderly workers, though, are generally encouraged not to retire and seek income support, but rather to continue gainful employment for as long as po11ble. Still, once the IIWWIWI peuioaable age 1 reached, usually 60 for men and SS for women, monthly financial a11istance can be received until death. the individual penaion rate is usually pegged to -le~gth of service and wage rate immediately prior to retirement. 'lhe elderly peasant in the rural areas, on the other hand, never to fully retire. lather, responsibilities diminiah with age and capabilitie1, but never completely cease until death is near. 'nle lack of financial independence relative to the urban worker generally create dependence upon family for the peasant (Wang Gongshi, 1986; Ma Bai De, 1985; Dixon, 1979). I For the aged v:lthout familie1, limited accommodations are available. lural commune have 1et up 10-called home of respect for the elderly. Likewise, municipalitie1 and provincial governments have built a limited DWlber of facilities and cantata for the elderly and disabled With no fm111e1 Somewhat.worrisome 1 the impending demand for accommodation for the elderly with no familiea. '1h11 d-nd 11 expected given Quna's one-child family policy.7 'l'he policy appear, to be meeting with some 7 In 1979, Sichuan province instituted a policy designed to persuade un:ied couple to have no more than one child. 'lhis policy was backed by a Yt of incentivu to parent who agreed to have no more than one child, and penaltiea for tho1e who persisted in having more than two. lecauae of great leapa in the population and decreases in infant mortality rate over the laat three decades, this policy was soon braced a national policy, and all provinces have now adopted such incentive and diaincentive aystema-including a provision th4t living 1tandarda will be maintained when they become old or widowed (World Bank, 1985) ',.,

PAGE 31

J () : .. :. ... / __ :_ : .) ':t 1ucce11, especially 1~ the urban areas 1uch aa Shanghai. To this po1 .. n t, thou1h1 there baa been no aystematic planning for 1ocial support policies and prograu neceaaary for the elderly and widowed parental population (Ma 1111 De, 1985; World Bank, 1985; Wana Gongahi, 1986; tu, 1986; Dou, 1986; Sbou Sbang Jue, 1986). ,. '1'he elderly are uaually acoura1ecl, even obliged, to invol tbaselves in neiahborbood or co11111Unity activitie1, especially aocial se~.c~ 'lhey alao are. encouraged to educate thaelves or to learn new handicrafts. Cultural groups, activity centera, and 61 so-called "universities of the elderly" have been organized and provided, eapecially in the larger urban aru1. Several of the oqal&izationa teach baaic preventive and 1elf-care akilla and behaTior1, auch aa T'ai Chi a:erci and principl. of good nutrition (Zhong, 1986; Wu taunjin, 1985). The 1Mr1ence of Geriatric Medicine Previoua diacua1io111 have touched on the health care ay1ta in China and th arioua a1pect1 of care that affect the elderly. 'lhere ia no evidence to indicate t~t pa_tteru of care for the elderly dif f ,.r aub1tantially from ochu ase group,. As pointed out at 1everal juncture, levels of insurance coveraa, urban-rural location, and specific placaent in the three-tiered 1y1t of 1e"ice1 are the aore 1ipuficant determinant of care ~or all age aroupa in Oliu. Unlike the special fiunclng prograu in the U.S.< Medicare and Medicaid) eatabliahed for the elderly, health care iuurance for the elderly i1 no different from inaurance for their younger counterparta. Bealth care 1cheae1 do vary, though, according to service in 1overmaent, military, factories, or rural countryside. 'lbe changing disease patterns of greater prevalence of il~uess of the aged (auch a, chronic illnes1) and the rapid increase in the number, of -fl r)9

PAGE 32

....... ........ elderly, thou1h, ~ve refocused medical education, research, and care to aome degree within the last five to tan year,. For example, while no reliable-figures are available, a substantial number of general and tuchin1-affiliated hospitals (above the di1trict l~vel) have opened 1pecial .units well as outpatient clinics for 10 called "geriatric diseases", including hyperteu1011, coronary hurt, chronic bronchiti11 and ao on. A nwaber of ho1pital1 also have been reported to initiate policie1 giving priority to the elderly for outpatient services. Newly e1tablished rehabilitation medicine centers and pharmacies also have established priority 1ervice for the elderly and commonly-found geriatric afflictions 1uch as arthriti1, 1troka, and hip fracture (Zhou Guanhona, 1986; Wu tuanjin, 1985; Mana, 1986; Be Jang Go, 1985; Lea, 1986; Li, 1986, Wang Gou11hi, 1986; Lo, 1986). luearch and evaluation in connection with geriatrics also has sprouted in Mdical 1chool1, colle1e11 and hoapital1 at all levela. 'lhe first 1eriatric research and treatment center i1 under con1truction in Beijing. &eaearch acro11 the country includes longitudinal 1tudie of individuals who reach advanced aae, di c011111only afflicting the elderly, mortality and aorbidity 1tudies, inveatigations on the mechanisms of the aging process,. predictive a0dellin1 of geriatric incidence and prevalence rates, and the illlunolo11 and paycholo11 of the aaed. ID addition, a mmaber of efforts have been initiated to invuti1ata preventive approaches t~ care for the elderly, and the use of traditional aad1c1ne approaches in diaposis and trutment. Several profeasioual organizations and journals fo~using on the elderly recently have been created. !or example, the Qdna Gerontological Aaaociation (which studies clinical care, but plans to expand its scope ~o include 1ocjal and economic conditions), and the Quneae Society of Geriatrics (which astabliahea standard of practic~ and gathers data related

PAGE 33

' to treatment) have bo_th been eatabliahed only within the laat five year, (Zhou Cuanhon1, 1986; Meng, 1986; Lee, 1986; Li, 1986; Lo, 1986; Wu Yuanjin, 1986; Bl Jana Go, 1985; Wang Gongahi; 198S). Trutaent of the Critically-aDcl Tend.nall:,-111 Elderly lioethical rraaevork. lot aurpriaingly, the cbanging dographic and ,,,, diea .patteru, a well aa the illitial gliaer of hi1h teclmolo11 Mdicine, have forced the Olin to begin facin1 more frequent questions concerning life, death and appropriate treataent for its elderly. Until recently, a relatively well-defined bioethical fr-work and the relative paucity of technologic opportunity have clarified treatment deciaioua. While the Confucian ethic illbu the C2uneH with a tradition of love, rupect and aupport for the a1ed, th11 baa never necarily translated into trutaent at all ~ot for aunival' sake (Dixon, 1979). binforcin1 thia attitude ia th aore recent aocialiat ethic that chooe public health .... urea and prefers m1n1 .. level of dical care for the maaaea over advanced trutaent for the few. At the riak of overaiaplifyiq, the ethical iaperative in the American health_care 1yat lligbt be characterized by the welfare of the individual,. wherus in Olina, the ve1fare of the 1roup :l.1 the pid:l.ng pr:I.Dciple. rurtheraora, the China Taoiat/0>Dfuciua tradition of congruity, harmony, ad the COIIIIOD 1ood baa 1111liaised conflict ud aurroundiq ethical dil- ner interpretation of this principal. Aa Pox (1984) ha observed, there is a noticeable lack of coucioua diacuaaion or concern over ethical dilemmas :l.n Ouaa relative to concern in the-United State,. (A Fox also implied, thouah, the individualin, com.petition, plurali, and wealth of this culture have bad the reverse effect of in some sense breeding ethical dil- surrounding treatment decisions.) 903\

PAGE 34

r -~ .... Deci1iomaakin1 Surrowdin1 Treatment. Discu11ion1 with physicians and prcr,ider1 in Olina typically reveal that treatment decisions surrounding the critically-ill elderly begin with proper diagnosis. Once that is determined, a judpent i1 made whether available treatMnt1 will be .. lif~avin" or "life-prolongiq_" (Meng, 1986; Win1, 1985) '!'his di1tinction i1 critical because provider will unhesitatingly begin to adaiDiater treatment in the case of the former. Importantly, we-saving" for the Olin implies not only. basic physiological functioning, but the retuni to some level of normal, productive living for the individual. For aaaple, if an individual i1 diaposed as 1uffering a brain hematoma, and de1pite' it roval, the patient may linaer indefinitely in a coma, the operation will frequently not be done. Such deci1iom do not to be a1e-.pecific; at least one cue of dialy1i1 beina denied a small 1irl becauae of permanent brain damage ha1 been reported in the literature (Fox, 1984). According to Meng (1986), the Chine are particularly di1cenung in ca of needed 1ur1ery becau1e of (or at least the perception of) po1t-ope~ative complicaticm1 or lona recovery periods. On the other hand, if -patient baa been diap.oaed "1th aome chroa.ic or termJ,nal illness, but treatment can even taporarily restore the individual to a normal, productive reaiaen th.re 11 typically little hesitancy (Lee, 1986). Por aaaple, the adaim.1traticm of traditional herb and medicines for cancer patient as a palliative (rather than restorative approach) is not UD.COIIDOD. Siailarly, the Chinese have some hospice-like facilities, either freeatancliq or more typically as distinct-part units of larger hospitals, for the terminally ill. Such care is also provided in small hospitals,. particularly those a11ociated with factories and universities, where beds be available (Mena, 1985). Dru1 therapies, often traditional medicine n-

PAGE 35

-q< I: f\_ _! i,.j ("" t, '-' I., !_ : j (J approachu1 are adaill:1,atered to maintain the patient in a comfortable state until death (Yu, 1986; Dou, 1986). 'l'h atrong exception to treat/nof treat decisioDS for liv-aving 1ituatiou 1 the dical -raency. A fairly clear coueuus among Olineae provider 1 to apply all neceaaary p,oceduru--ruuscitation, ventilation, and ao m-to aave and stabilise th patient until a decision about further trutaent plau can be decided upon (Li, 1986). In the larger hospital1, t .... of 1pecially-trained eraency room personnel are often available for ruuacitation procedure,. Only with patients in advanced stages of cancer do phyaiciau readily fore10 raauacitation aeaaure1 (Shou Shang Jue, 198S). Oaca the patient 1 placed on 118Chanical ventiltion or other 11fe-euatain1q taclmolo1ie1, vitbdral ~f_t:19eataat becOMI aore difficult. lrain death 11 not ued a1 a criterion for vithdral either, hut auat be accoapam.ed by the 1toppiq ()f the hurt (Haq, 1985). Delpit policy effort in the recent pa1t to downplay the iaportance of the auclear faily ad.11&1 it i the faily that uaually decides upon appropriate treataent1. 1.'be individual patient Y or uy not be told of the diapo111 and corre1poacliq climcal choice,, but rarely does the illdivictual decide alone Inatead, it 11 the appropriate family ber1-the parent ia the ca of a 7ouo.1er peraoa, the aon or daqhter ad 1pouee1 in tbe ca of the a1ed. It 11 also the fud.ly that 11 1nforaed first of the clinical status of the patieat, and death ia never aplicitly cliacu11ed with the patient. '!'here ii no evidence that written conaent fonaa are ever u1ed in connection with treatment. Like~ there would appear to be no formal procedure ucbanias for attaiD1n1 con1ent, though tradition and custom have replariaed the process to a aipificant extent (Mang, 1986; Fox, 1984; Lee, 1986; Wang, 1986; Gao Li, ~985). 0a the other aide of the consultation proceaa, it ia interesting to note H'-

PAGE 36

..... ...... that doctor, iD O)ina are not necessarily advocates of treatment like their Weatern counterparts. Further, there is little evidence that Olinese governmental or legal authorities attempt to impose explicit ethical choices (out11d~ of broadly e1tablished bouudaries) a 11 sometimes the policy in the United States, such as with therecent case of Baby Jane Doe (Fox, 1984). In the event that treatment ia refused, the patient ii normally sent home. Many who refuse, thou1h, uy seek treatment elsewhere, r~ceive the 1ame advice, and later consent (Meng, 1985)-perbaps to assure continued hoapital care. More probleutic are patient who, on their own or through their faaily, inaiat on treatment a1ainat the physician's recommendation. A physician uy air to provide treatment in order to avoid complaints to the boapital adainistration or t~ the local health bureau (Lee, 1985; Geng, 1985). Closely related to this 11aue is the issue of malpractice. Medical ulpractice aa Americana know it would notappear to be an issue in Qlina. Confucian tradition precluded tbe hiatorical growth of a body of common law, and there 11 no civil law to 1ettle di1pute1 among individuals. Not aurpriaiqly, liability inaurance i1 laqely unneeded a result. What is needed, :however, i1 the a11urance-that-the proper diaanoatic and therapeu~ic re1illena are beiq undertaken. To aaaure this, physiciam often work in t .... and develop coueuua when difficult ca are deliberated over. Chinue pbyaiciau do fear not only the posaibility of clinical aistakea, but the possible public barrasnaent and of face". Even so, physiciau rarely are penalized in any form by the state, and peer review proce are both rare and non-binding-education (or "re-education") is uaually the only "punishment (Tung, 1986; Lee, 1986; Fox, 1984). According to Geq De-Zhena (1985), patienta or families can request hospitals to coapeuate for provider mistakes. Inatitutiooal committees, not court, '~

PAGE 37

' .. (\ tbouah, evaluate th_~ndividual case and make the,deciaion concerning the level of just coapeuation. Large, urban hospitals may have one or two such caau per year. 'l'h laraeat single payment awarded to date has been 4,000 yuaa-about t1,200. Laatly, accorcli111 to LN (1986), the Chine are now atrugliq in the public forua with the iaaue of the ri1ht to foreao treatment. Qsrrently, before th People' Aably in Beijiq ia a propoaal whereby phyaiciau would not be obligated to tr,at the patient if the following patient conditiona are preaent: the patient 1 in the final 1tate of a diaeaae, the heart baa atopped bu.tins for 5 ainute1 or more, or rupiration baa not taken place for 20 ainutea or aore. Die propoaal, boweYer, 1 aiven little cballce of enactnt in the near future. BcODOllic ractora. lcODOllic and financina factor incruaiqly affect treaClellt deciaiou in the new C2aina, eapacially ainc the iutitution of it urket refonaa. Aa previoualy diacuaaad, level of iuurance coveraae topther with plac-nt in the urban or rural traufer/referral ayat are c;rueitldeterainanta of the type of care received, a vella the aailability and pattern.a of utilization of Weatem teclmologies (Bender1on ancl Cobm, 1981). Additionally, tbue factor will in laqe part detenaine elilibility for plac-nt in apacial aariatric reaurch and treataent cater diacud earlier (Heq, 1986). Other than placaent in theae um.ta, though, available evidence point, to Ulldifferentiated utilization pattarna of proceduru and teclm.ologiu for the critically-ill elderly/non-elderly within individual hospitals or facilitiea. If, for uaaple, a large apecialty hospital in Shaqbai was well-equipped with vantilator-aaaiatiq druga, dialyaia aachinea, and apecialty unit, diffaracea in uae reflected levels of covaraae and cue a1x rather than 3t JS

PAGE 38

-.. ".:'It .. patlanta' aau (Z~ou, 198.5; Waq Gougshl, 1986). '1'b.ia was rather overtly argued by at least one Chinese administrator of a navly formed and non-aovermeut supported hoapital in the south of the c~untry, vbo atatecl that evm if a patient waa near death but had no 1uurance, 1/be would be tran1farrec! or sent home a quickly as possible. 1'11 luurad patient, on the other hand, would be 1iven treatment (regardless of affective) a loq aa it would be requeatad by the famil,: (Lo, 1986). Siailarly, it 1 not uncommon for the rural, poorly-insured patient to have auch aborter hospital 1tay1 on averaae than his urban, well-insured counterpart. Indeed, there 11 1oae evidence that families in urban areas often requa1t that their relative ba kept iu the hospital aa long as po11ible-even until deat~. ID the nev Cbiaa, aore and more urban patients are dyiq in the ho1pital, not at ho. '1h11 in part reflects the houaina 1horta1u in urban arua .inpruent-day China, and reflects the inability of faili to care for the elderly at home 1ivan that husband and vife are comaoniy both aployed full-time (Le, 1986). Meq (1986) has observed that uepiq relati in th hoapital alao a11ure aaaimt le1al/1ocial alle1atiou of ne1lect .On the provider 1ide,.the.vut majority of phy1iciau are salaried at level.a predetel'llined by the 1overmant (Bliao, 1984). Ulllike the 1ituation ill the Ullited States, there ii little ruultiug acouoaic incentive to Ulldertab mmece11ary 1urgeZ7 or procedure,. LibwiH, they are often conatrained by the liaited availability of aedical equipaent and supplies A reverse 1ituatioa 11 the 1overment aub1idiziq of pha;,aaceuticala, vacclnu, ud antibiotics. To the extent that the price of these is set artificially low, opportunities and some evidence (World Bank, 198S) exist u to their overutilizatioa. !broa1h all of this dlacua1ion aurrOUDdiug deci1ion1 to treat the _J_

PAGE 39

i n ") f_ ,J i.: _;;_ .... ,_ criticall,-and tnd:~,-111 elderly, it ia iaportant to aaain keep in ~ 111.nd that Olilla 1 cbaqiq. ID the pursuit of aodernization and national N<h, 1ndiv1dualia, competition, and plurali are aaaumin1 new aiplficanca. A a few aelectacl aedical cutera Waatarnize and modernize, ad phyaiciau aove avay fra11 ulary-baaacl pa,-nt, differiq style and lnela of quality of care Y 1enerata a whole new aet of deci1iC'DNkiq procuau and ethical clil-. One clue u1 be the recent aperience in relatively affluent, modern, and laraely Chineae (98%) Bong Kong, where rationiq policiea for kidney dialyaia have recently been developed, and which laqely place the elderly laat after aoat other groupa in priority of auilabl care (Laa, 1986). DIPLICAUOIS FOi ANDICAR POLICIES Olin provicler1 and polic,-ken laqel.7 believe that Olina baa auch to lun fraa the watern aperiace in the trutaat ad care of the criticall,-111 elclerly. 1hia bu ban obaened in C2lina'1 recant daaoutratiou tbat it nt to becoae the latut eaaer American 1mitator ill it parauit of tachnologle1 such a1 er acaDDer1 and apeciali. Rnertheleaa, there woul.cl to be iaportant luaona that the Chinese can offer thia count17. ror ona, C211 traditioaal uclicine ad a wide variet7 of other herbal and clical preparatlou have poaaibly provided the aunese with coat-effective alternatives to aore_apeuive Weatern therapies. Unfortuaately, little 1 known or UDderatood pirically about levels of fety, efficac7, anc1 effactlveneaa of traditional approaches and regi11ens. Iaportant efforts now are underwa7 in China to improve biochemical knowled1e of the active iqredlenta in ll&DJ of the herbal preparati01l81 and attpta -1'3]

PAGE 40

... to initiate scien;ific inquiries into this area enjoy stron1 support from the M1D1st ry of Public Baal th. Some American drug companies and universities (e.1., the University of Kentucky) have performed research in this aru (Handerson, 1986). Because the manufacture of Ou.naae drugs, pharuceuticals, ud other preparations are ezclusively under the control of the.1overmant1 though, there is little market incentive (in terms of new rkets in Olina) for Allerican concerns to invest in this area. Due to the potential application in American medicine, thoush, Cons~ess may want to consider incentives to firms in this country to carry out research and development efforts. Such incentives could include 1rants or cooperati~e qremaauts, or financial tu incentives similar to those structured under the recent Orphan D'rug le1islation. Secondly, the policy direction in Olina to decentralize clinical and economic de~iaioamakiq to the extent possible warrants careful watching. Early evidence indicates that this policy will generate greater disparities of access and quality care than presently exist. 'lb Ullited States also has experienced such lessons in the past that parallel this experience. For exaaple, th Kerr-Milla le1ialatio11 in the early 1960. authoriz~d health care cov~ra1e for the incli1at elderly, -~~_!~le1ated 11\lC~_o_f the f_i~_!~in ancl dacisi~muking to the States. One result was unacceptable differences in the provision of benefits and ruultina care. t'he recent impetus to privatize and further decentralize health proarau for the elderly not only should reflect upon historical Amerie&D experience, but upon contemporary ad lessons as well. thirdly, despite the current infatuation with expensive medical teclmolou and the relative disre1ard for their true coat-effectiveness, the Chinese have made efforts and i-uroads in designing and implementing prevention ,olic1 and atrategi for its elderly and chronically-ill. -11-_J{ ...

PAGE 41

J ., '. !' ., 'I -J '---.J & Becauae of the auccu with preventive policiu for acute ill.Des, the social, political, educational, and economic planning and proarau in this aru aay prO'lide the U.S. and other Western natiou leaaons and opporbmitiu for re health care cot uvinp. 'l'hi 1 upecially iaportat u 10111 a tbe priaar, concern in the U.S. Jt continuu to he coat-ccmtailllNllt. !here obviouly are iaportant cllfferac .. bet11Nll C2lina ad the United States. 'lb include differences in the atage of development and induatriallzation, dao1raphic profile, nature of hiatorical health probl .. d .. ree of cultural unifonalty, difference in interplay between aciatific and folk belief about health and illness, and differences in political and ecoDOllic ayt-. 'lheH differacu abould not obacure our 1Dcreuiq aiailaritiu, tboaah, or the luaou tbat are poaaible for both utiou. -,a--3?

PAGE 42

-... -=-. ... ll!FERENC!S Aaarican Boapital Association, Boapital Statistics, Chicago, IL, 1982. Berki, Sylvester, University of Michigan School of Public Health, Ann Arbor, M:lchi1an, personal coaainicatioa, Janua~ ~986. liacbo, J.J. obaerved U of Acupuncture, China Medicine As We Saw It, Johll !. Foa&rty Internatioaal Canter, U.S. Department of Baalth,. Education, and Val.fare, Publication Ro. (KIi) 75-684, Washington, DC, 1974. Capra, Fritjof, Tbe Tao of Physics, Bantam Books, New York, NY 1976. Chang, M.lt., --Sursing in Qliu: three Perspectives, American Journal of Hur,ing, Vol. 83, No. 3, pp. 389-91, March 1983 Cbao, L.M., Gong, Y .L., and Gu, S .J., rinanciq the Cooperat-ive Medical Sy1taa, .. Aaricau Journal of Public Baalth, Vol. 72 (Supplement), pp. 78-80, 1982. Ola, Pi-chou, and 011-Baia Tuan, -itt-iury Health eare in l.ural China, Sccial Sciaca and Medicine, Vol. 17, No. 19, pp. 14ll-17, 1983. Cbeq, XJI., and Ye, x.r., eoat ~Y of Medical Care, American Journal of Public Bu.1th, Vol. 72 (Supplaaent), pp. 81-82, 1982. Dobson, Alla, ealth Care in Olina After Mao, Health Care Financing l.niev, Winter 1981, Washington, DC, 1981. Dou, Za-Ml.n, Hinist:y of Public )$aalth, Beijing, People's llepublic of China, personal couaunication, January 1986. Pia~er, G. Sandra, .'l'h OgaDizati011 of bocial and SupportJ.ve Services for Older People in the United States: Implications for Social Servies in Cllina, U.S. Adllilliatration on qing, Vashiqton,' DC, 1985. roz1 Stffen, ppocrate Unbound: Ouna'1 Medical Educatiou for the 1980s, JANl, Vol. 2511 Ro. 4, pp. 490-94, January 27, 1984. ra, Stnera, auna: Diar, of a Barefoot Bioethicist, Baat1n1 O!nter a.port, pp. 18-20, Dacbar 1984. Gav, A.C., Olang, L.V., and Shaw, L.-C., Efficac1 of Acupuncture on Oateoarthritic Pain, Nev Ensland Journal of Medicine, Vol. 293, No. 8, pp. 375-78, 1973 Geq, De-Zheng, Beijing, People' llepublic of Olia.a, personal commuuication, Decber 1985. G11aapon1 Provincial Institute of Geriatric Medicine, A Comprehensive Study on Centenarians in Ouaa, unpubliabed, People' s Republic of Quna, no date. w ---

PAGE 43

.. Guaqzbou, Yi-Shou Bo~pital, A Brief Illtroduction, unpublished, Guangzhou, People' 1 llepublic of Olina I no elate. Ba, 11.iide, Beijing, People' B.epublic of China, per1onal communication, Decnber 1985. a., Jaq Go, leijiq Boapital, People' l.epublic of Qiiu, peraonal cowillication, Dc'ber 1985. Baiatauqer, Dou1la1, o'bNnatiou 011 the Practice of Clinical Nutrition in Boapitale 111 Qiiaa, Journal of Parenteral and lnteral Nutrition, Vol. 8, Ro. 6, pp. 628-31, lovber/&cber 1984. Baadenon, Alfred, EmbaY of the Uited State of America, Beijing, People's republic of. _Olina, personal c011111Nnication, January 1986 Baaaraon, G., and Cohen, H.S., ealth Care in the People's llepublic of Chiu: A View from Inaide the Sy1tem, American Journal of Public Health, Vol. ~2, Ro. 11, pp. 1238-1%44, Rovber 1982. Blaio, w.c., "Tranafonaatiou of Baalth Care 111 Chiu, New Enaland Journal of Nediciu, Vol. 310, lo. 14, pp. 932-936, April S, 1914. Byatt, 1., and Peldaan, aobert, Oline Bar'bal Medicine: Ancient Art and Modem lledicim, Schocka Book1, Hew York, Rt, 1978. Jain, E.E., !he Aaziq Story of Bealth Care in Rew Qiiaa, l.odale Preas, lallau11 PA, 1973. Lao T&q., The W&y and It Povar1 no date. Lee, Zhi-Sia, Chin Medical Aa1ociation1 Beijina, People' B.epublic of China, paraoaal c011111U11ication1 Deceaber 198.5 and January 1986. Li, C.P., Oline Ber'bal Mediciae, U.S. Department of Baalth, Education, and Welfara1 Public Baalth Service, lational IDatitutes of Bealth, Publication lo. (RIB) 75-732, Waahin1ton, DC, 1974. Li, Cao, leiji~g, People' B.epublic of China, pereoaal cOllllllUDication, Dacber 1985. Li, lei-lioq, Guan1don1 Provincial Institute of Geriatric Medicine, Gu1npo111 Province, People' Jlapublic of China, paraoaal comunication, Jamaar, 1986. Li, l'ei-J1.on1, Sauna, P., Li, C.B., and Ju, L.E., ayperteuioo in the llderl1 in C2l!aa,cuan1dong Proincial Institute of Geriatric Medicine, unpublished, Guangdona Province, People' llepublic of China, no date. Liu, Y.C., ai1na: Bealtb Care in Transition, Nursing outlook, Vol.31, No. 2, pp. 94-99, March/April 1983. Liu, Yuen Chow, China: Traditional Healing and Contemporary Medicine, International Nursing lleview, Vol. 31, No. 4, pp. 110-114, 1984. -IA' ,J/

PAGE 44

., .:'IP. Lo, Timothy r..c.,. Gan1zbou tiahou Hospital, Guangzhou, People's Republic of China, personal c011111UD.icat:ton: January 1986. Ma, Bai De, "B:tstory of Eradication of Venereal Diseases in the People's Republic of China," presentation at the National Institutes of Health, lethelda, Maryland, Aupst 13, 1985. Macek, Catherine, "lut Meets West to Balance Imunologic Yin and Yang," JAMA, Vol. 2.51, No. 4, pp .433-439, January 27, 1984. Maag, J:ta-Ma:t, Be:tjiq Second Medical College, People's Republic of China, persoaal cOlllllUDicat:ton, Decber 198S and January 1986. Peopl~'s Publi1hing, Statistical Yearbook of China, Beijing, People's Republic of Olina, 1983~ Prescott, N. and Jamison, D.T., "Health Care Sector Finance in Chiaa," World' Health Statistics.Quarterly, Volume 37, No. 4, pp. 387-402, 1984. Bandel, S., and Soon1, LiqLing, "Traditional Chinese Medicine in China," 1'he We1tern Journal of Medicine, Vol. 39, No. 2, pp. 236-238, August 1983. Sua1al1ki, Alan, and Buckley, Michael, China: A Travel Survival Kit, Lonely Planet Publications, Berkeley, CA, 1. Sbi-Tzi, Siang, "Use of Combined Traditioul Chinese and Western Medicine in the Managaent of Burns, Paminerva Medica, Vol. 25, 1983. Sidel, v.w., "Medical Care in China: Equity Versus Modernization," American Journal of Public Health, Vol. 72, pp. 1224-26, 1982. Shu, Shang Jue, Beijing, People's Republic of China, personal communication, Decber 1985. Sidel, Victor w., and Sidel, Ruth, A Healthy State: An International Perspective on the Crisis in United States Medical Cara, Pantheon Books, New fork, ft l983. Sidel, Victor w., and Sidel, Ruth, Serve the People: Observations on Medicine in the People' llepublic of Quna, Beacon Press, Bo1ton, MA, 1974. Snow, Eqar, lad China Today, Vintage Books, Rew York, NY, 1971. Steiner, a.P., Acupuncture: Oiltural Perspectives (2. 1.be !astern View), Po1t1raduate Medicine, Vol. 74, Ho. 4, pp. 71-78, October 1983. Sumerfiald, John, Fodors People' Republic of Olina, Beijing, 1979. Tang, Vincente, Embassy of the United States of America, Beijing, People's Republic of Oiina, personal communication, January 1986. U.S. Department of Health, Education, and Welfare, Medicine in Chinese Oalture1: Comrarative Studie1 in Health Care in 0!.ine1e and Other Socletlas, ile man, A., ltumtadter, P., Alexander, E.i., and Gale, J .L. (editor1)1 Government Printin1 Office, Washinaton, DC, 1975.

PAGE 45

"\' S:.''~ .... ... 1,; .. .... -.-,...,,,J._. . (' ... .... .. ... ~. ,,. t n : ,: .. -(J Wna, Goaaabi, Ouna National Committee on .Aaing, Beijing, People' Republic of Cbina, peraoaal coimaunication, January 1986. Wna, Jiu La, Mini1try of Public Health, Beijing, People' Republic of China, peraoaal c011111Unication, January 1~86. Was, Za-Sbu111 -Dona Baapital, Sbaqbai, People' lepublic of Ouna, peraonal c01111Ullicatlon, January 1986. World Bak Atlaa, lopulatio11, hr Capita Product and Growth late, World Batt W.abiqton, DC, 1113. World Bak, China: Tba Bealth Sector, Wa1hington1 DC, 1985. Wu, Yaunjin, Secretary General, National Committee on Aging, Beijing, People's lapu~lic of China, personal counication, December 198S. Wu, Yina-1&1, pideaiology and O>amnity Control of Byparten1ion, Stroke, and Coronary a.art Diauaa in Qiina, unpubli1had, Chin Academy of Medical Scimcaa, Be1j1111, People' lapubU.c of ~-. no date. Yu, W.n-fu, IU.aiatry of Public Baalth, laijiq, People' B.epublic of Olina, paraonal coanmicatio11, Januar, 1986. Zhana, LiD., la1j1q, People' Bapublic of China, paraonal com.unicatiou, Decber 1985. Z11on1, Zblchaq, Baaltb luruu of Guanpoq Prov111ee, Guangzhou, People' Republic of Oiina, per1onal coaaullication, Janua1:7 1986. Zhou, Qaenh'XII, A l.aport on the PraventiOD and Trutaant of Geriatric Diau in Sbaqbai, UDP!lbliabed, Sbaqbai Public Bu.1th Bureau, People's lapublic of China, no data. Zhou, Guaa.boq, Shanghai Public Bealth Bureau, hopla'a Republic of Olina, per1onal c01111Ullicatiou1 Januar, 1986.


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