The high priests of medicine: U.S. and Chinese hospitals

Chicago, 1999

One day the previous December I was out jogging and my calf muscles cramped up so badly I had to limp home. The next day they were swollen and I continued to limp. The day after that my lower back became inflamed, making it even more difficult to walk. My back would bother me one day, my calves the next, some days both, and everyday I walked laboriously with a limp. I blamed it on a back sprain probably caused by lifting my wife out of bed. She loved to sleep and it was one of the more effective ways to get her up. My nurse practitioner thought it was a muscle spasm, pinching my motor nerves. A muscle relaxant was prescribed and I was told to follow up when it got better. It did get better in the sense that the pain went away, but the limping remained. Finally some six weeks later, she sent me for a spine x-ray and an appointment with a neurologist on the assumption it might be a nerve problem. I was suspecting the same thing.

In Neurology, an intense blonde in street clothes, Dr. Della, asked me walk on my toes, which I couldn’t, dragged a pin over my legs and feet and hands (where I was also feeling weakness), and pushed, pulled, poked and prodded my limbs from a squatting position in front of me. The concentration on her face contradicted the cleavage her v-neck shirt offered to my vantage point. A goofy-looking intern with acne appeared in the room. Dr. Della made him identify the nerves involved. He got one right, hesitated on another. I seemed to hear her saying in her head: You and your generation with your computer games and pizza and backwards baseball caps have the presumption to become a doctor! You probably think the Hippocratic oath is a joke and nobody believes in anything so corny anymore. You think that doctors don’t save lives because they believe in it but only for sport, to see who can save the most lives for fun. Why can’t we just do our job without all the moral crap? Well, medical training isn’t a computer game, buster. You have to memorize things. After a withering silence, she announced the correct answer. He beat a hasty retreat.

No less than the Director of Neurology, the “great Dr. Mercure” (in the words of a colleague) then made his appearance. In his 40s with a mustache and professional mien, he looked straight ahead as he strode into the room, the way a concert pianist makes his way for the piano without looking at the audience, not glancing at me until reaching a certain invisible spot from which to pirouette and conduct his diagnosis. He ran through the same routine, at one point asking if I had had the flu lately. I told him I was stricken with pneumonia back in October. “Let me do a few more of these tests and then we’ll talk,” he winked. When he finished, he pulled up a chair.

“You have what I’m fairly certain is acute motor axonal neuropathy. It’s an immune deficiency that occurs occasionally with the flu or pneumonia, for reasons we don’t understand. Basically, your immune system attacked your pneumonia too aggressively and attacked your own cells in the process, causing nerve damage.”

“Is it permanent?”

“No, it’s treatable in most cases. Most people improve 90-100%. Some have a relapse, and that’s also treatable. But we have to run you through some tests to make sure this is what you have.”

“How common is it?”

“It’s not uncommon. We get one or two cases a month here.”

“So it’s not a muscle spasm?”

“No.”

“I was all set to go to a chiropractor. I guess that won’t do any good.”

“Probably not.”

He described the strange tests I would undergo over the next two weeks: an EMG, where they shoot bolts of electricity through your limbs to see if your nerves jump right and then stick a needle with a tiny microphone into various muscles to see if they sound right when you flex them, amplified on speakers; a scary procedure called a lumbar puncture (aka. spinal tap), where they insert a thin pipe into your lower spine and let a measured amount of the spinal fluid squirt out into a vial; and an MRI of the brain and neck (“Just because I don’t want any surprises”). If all went well, the usually effective—again for reasons they don’t understand—treatment that followed would require infusing someone else’s immunoglobulin (blood plasma) through my bloodstream.

“Do you have any more questions?” Dr. Mercure said as he wrapped up.

He didn’t rise out of his chair as doctors customarily do, but remained seated and even waited a few moments to give me a chance to work out a question or two. I was impressed; only teachers are supposed to know this trick. Some doctors are so urgently on their way out the door you feel one measly question is a huge imposition. Admittedly, health maintenance organizations are making doctors see as many as seven to eight patients an hour these days, so it’s not wholly the doctor’s fault. Now what’s interesting is that with ranking physicians like Mercure who don’t have to run through quite as many patients, it can still be so hard to fit those damn questions in. And the reason the doctor is not really paying attention to you is that you are witnessing a performance, one you are not scripted into because you are the audience.

Then it occurred to me why some doctors wear white gowns and others don’t. It’s not status per se; both Mercure and the goofy intern wore gowns, while Della didn’t. What the white gown does is throw certain details such as their name into relief. The mock-aristocratic cursive lettering, sewn into the fabric over the heart like a badge, renders the performer’s role plain and unmistakable, as on a dramatis personae page. I guess Della eschewed the gown as a sign of rebellion, not against the career of medicine itself—Mercure told me she was “compulsive” and I was in good hands with her—but the prospect of playing the same role over and over again for her whole career, something she may not yet have resigned herself to.

The tests results came out as expected, which eliminated the possibility of something horrible like ALS or some other progressive wasting disease. I began immunoglobulin treatment in the hospital hematology clinic, a regimen of five six-hour infusions five days in a row. Before letting the daily $1,200 pouch of immunoglobulin start dripping through, the nurse injected me with 25mg of Benadryl to mute any adverse reactions. This over-the-counter anti-allergy drug makes a good sleeping pill. It works gently and I hardly noticed it at all, except that the clock changed from 10 am to 1 pm in what seemed only a few minutes.

The only inconvenience was staring at the TV the whole time. Another patient wanted a video put on, and we all watched Top Gun. Then a live news conference at which former Chicago Bears running back Walter Payton and his doctor announced he had a rare, incurable liver disease and needed a donor or he would die. His sunglasses couldn’t disguise how ill he already looked (the conference was intended to quash rumors that he had AIDS). I have no interest in sports, but I have to say I found it moving. When a reporter asked Payton how his friends were dealing with it, he broke down, the microphone wobbling in his hand, and he was escorted out. I guess I had it pretty easy, with my little peepshow into the hospital experience.

Mercure warned me I might experience slight “flu-like symptoms” over the course of the treatment, but I felt nothing and seemed to be reacting well. But just as I was settling into bed the night after the second day’s infusion, I was slammed by the most thunderous headache of my life, a relentless, piston-pounding BOOM BOOM BOOM lasting the whole sleepless night and until noon the next day without letup. It felt as if an alien had invaded my head. A couple Tylenol had no effect. I tried paging Mercure with no results in the morning; he was in different hospitals everyday and I was bumped from one secretary to another.

“Why didn’t you call me last night?” he said when he finally he got back to me.

“It was after midnight.”

“What did you tell my secretary?”

“That it was pretty bad, but I didn’t think it qualified for an ambulance—”

“Why didn’t they give you the right number? Why didn’t she know I was to be paged?”

The unflappable Dr. Mercure with his guard down! At least it wasn’t me he was angry with.

“OK, take 800 mg of ibuprofen now and 600 mg twice more today and come down to the clinic this afternoon. I won’t be there but I’ll have someone else see you.”

Mercure took me off the immunoglobulin for two days, resuming one final infusion at the end of the week, which caused no reaction. So if each infusion was $1,200 worth of immunoglobulin, that meant that my headache just saved my insurance provider $2,400. A $2,400 headache. Funny how money comes and goes. Hey, wait a minute, shouldn’t I get the $2,400? In any case the treatment started to work by the end of the week. A month later I could walk at normal speed and had started jogging again.

Arriving at my final follow-up appointment, I passed by a woman in the hallway who smiled at me. The first doctor to appear in the consulting room was a new one with a Mediterranean face and a Russian accent. He felt obliged to inform me, as Mercure previously had, that while the immunoglobulin was routinely filtered twice for HIV and Hepatitis C, “there’s a lot of stuff in there,” meaning potential disease agents, “and who knows what they might find ten years from now.”

We were joined by Mercure and the woman I saw in the hallway. It was Dr. Della. She had cut her hair short and dyed it brown, and wasn’t wearing her glasses. No doubt about it, she was unquestionably hot.

“I didn’t recognize you,” I said. “You dyed your hair.”

“I know, I got bored!”

“So the immunoglobulin is pretty clean?” I asked Mercure.

“We think it is. But there’s no guarantee.”

“Is American immunoglobulin the best?”

“Actually Europe has stricter screening standards, I’m told.”

“I’m moving to China this summer, and I’m wondering, if I had a relapse, could I get the same quality immunoglobulin in Beijing?”

“Coming from the same kind of situation myself,” grinned the Russian doctor, “I can tell you that they have the very best, and they have the very worst.”

Della was staring off into space, hands wedged absentmindedly in her groin. That’s an interesting cultural difference, which you never see in Chinese or Japanese women. They get their hands slapped at a very early age for doing that. Which brings me to the moral of the story: the sexual pleasure I began to take in getting shots.

It all started with my PhD dissertation. It was directly to blame for all my recent health problems. The previous June at the end of a busy semester, when I was ready to start writing, I developed, for the first time in my life, severe insomnia. Four-day cycles of no sleep. The insomnia got better after several months of cognitive-behavioral therapy in the mental health center, mainly due to the realization that I was beginning to make progress on the dissertation. But months of inadequate sleep had compromised by body’s immune system and made me more prone to illness, such as pneumonia, which in turn led to the nerve damage.

And lots of shots. What’s curious about shots is that no two are alike. It’s a different pain each time: now a sharp puncture pain popping like a bubble; now a sleek pain from the sliding of the needle through the skin; now a wily pain catching you off guard with a nasty pinch. Shots became interesting to me. I can almost say I began to look forward to them, just for variety’s sake. Each shot seemed to have a personality of its own, as if the needle had the ductility of an erect penis or could move of its own accord, creatively finding a new way to enter the vaginal pore each time, perhaps by thrusting straight into the flesh, or dipping in at an angle with a certain finesse, or hooking into the skin and feeling around for a moment before driving home….

Beijing 2007

Numerous visits to Xiehe Hospital over the years for various medical problems hammered things down to a system, considerably simpler than visiting an American hospital. The hospital is divided into two sections, the main complex for Chinese nationals and a smaller wing for foreigners. Doctors who speak passable English do shifts in the foreigner section and receive higher fees. You can use the Chinese side and pay a dirt-cheap registration fee but have to arrive very early in the morning and wait for hours to see a doctor (there are no appointments in Chinese hospitals except for major procedures such as surgery). Even then there is still no certainty the doctor has time left by the end of the day if too many patients got a leg in before you. Then you have to start all over again the next day.

Upon entering the foreigner section, I pay a fee the equivalent of $15-$45 depending on the rank of doctor available. They fish my file out of the cabinet with impressive speed (arranged by nationality of patient), containing doctors’ handwritten reports on all my previous visits. I have two files, actually, one from 2003-6 and a new one I started this year. The earlier one got so bulky I grew tired of explaining, while the doctor paged through my illegibly scrawled medical history, that my present visit really is unrelated to any past conditions.

How did the new file get started? I pretended to be visiting for the first time and used different Chinese characters to refer to my name. They don’t know I have two files. Even if they computerize everything, I’ll still have two files since I have two identities (ID numbers only apply to Chinese citizens). If I continue to use this hospital down the line, I’ll start a third file when the second one gets embarrassingly large. Whichever file they pull out serves my purpose and I grab it from the receptionist. She asks me what the problem is. I tell her a pain in my groin area. She directs me to a general practitioner in Room 1 left down the hallway.

The wait to see the doctor is usually no more than a few minutes. Sometimes he or she is sitting there in the office waiting for the next patient and I can go in. There is no nurse to summon you. You simply open the door and walk in. If you chance upon a naked person being examined, the doctor will ask you to step outside and wait your turn. On more than one occasion have I had patients barge in on me with my pants down. On this occasion I am pleased to see it’s a young urologist I am assigned. Younger physicians are more on the ball and up-to-date on the best antibiotics.

He fingers my testicles and writes out slips for more tests. Before taking the slips to the nurses’ station, I have to pay for the tests at the cashier—$180 US (major credit cards accepted). This is how things work in China. You literally get what you pay for, and it seems the more crucial the service the stricter this practice is. If your money runs out on your home electricity, heating or water before re-juicing your card at the bank, they’re shut off without warning. Similarly, some hospitals, I’ve been warned, won’t operate on you in an emergency if you can’t present the money or an insurance card upfront (try not to arrive at the hospital unconscious).

After a blood test for PSA (prostate cancer), I am sent upstairs for ultrasound tests of my prostate and testicles. It’s already 4 pm and they have just shut down the machine but are still there. They escort me over to the main hospital wing. There is a male technician, his female assistant, and several other female technicians in the room. They watch with mild curiosity as I take off my pants and underwear and lay back on the table. My technician’s assistant shows an interesting etiquette, however. She only looks at my groin when he does. I have passive exhibitionist fantasies and don’t mind, and no, I don’t get an erection, even as the transducer probe, lubricated with jelly, glides gorgeously over my balls (though I might if she was wielding the probe instead). Come to think of it, I did once get an erection when a hot Chinese nurse stretched her head around to steal a glance at my cock when giving me a booster in the ass. In any case it isn’t so much voyeurism as your body being in a sense public property in China, not wholly your own, so people are at liberty to look at it or touch it without the expectation that you will take offense.

I rush back to the foreigner wing for a urine test before they close. Then I am back in the urologist’s office, all in the space of 30 minutes and with all the test results in hand. He tells me I have a slightly enlarged prostate (common in men my age) and a mild case of varicocese, an inflammation of the sperm duct. Neither condition is serious enough to warrant treatment or medicine, though he does prescribe pills for pain if I need them—a ten-tablet box of Oxycodone, an Oxycontin relative, the highly addictive pain killer that prescription drug freaks held up pharmacies for in the movie Drugstore Cowboy.

The whole procedure is remarkably efficient. I walk into the hospital without an appointment and am able to see a doctor almost immediately. Instead of the test results winding their way electronically through the hospital bureaucracy, I literally carry them from one office to the next and turn them all in to the same doctor.

Xiehe has undergone countless changes and renovations over the last century and this. The hospital’s original name (still in use among the foreign community) was Peking Union Medical College, founded in 1906 and funded by the Rockefeller Foundation. For decades it was the only foreigner-designated hospital in Beijing. Its Chinese-style architecture was designed by of all people the eccentric expat Englishman Edward T. C. Werner, whose daughter Pamela was murdered and mutilated in 1937 in Beijing (her autopsy performed in the same hospital); the story is vividly brought to life in Paul French’s Midnight in Peking.

The hospital has undergone a major expansion in the years since my prostate procedure. China has lately been experiencing a massive internal migration from the countryside to the city. Migrants or “outsiders” have been pouring into the capital alone at the rate of half a million annually, pushing the city’s population up to 30 million or more by some estimates. Beijing is regarded as having the best of everything, including hospitals and medical care. This lopsided situation has resulted in Xiehe and a few other reputable hospitals being swamped by ever-greater numbers of patients with grave conditions hoping for a cure, including not just migrants living in the city but many more from outlying areas making the pilgrimage to Beijing for this purpose.

At some point word got around that domestic visitors were not forbidden from using the foreigner wing. They could thus get the same immediate service by merely paying a higher registration fee of about US $50. In the past this might have been prohibitive for poor peasants but is peanuts today. The other recent development was the institution’s rebuilding and expansion into the most massive hospital structure I have seen anywhere, designed to accommodate the big new tidal wave of patients—and profit from them.

The foreigner wing has now been moved to a section of the new building and is extremely crowded at all times of the day. Walk-ins are no longer allowed; one must make an appointment by phone, and the line is always busy (I hear they are working on an online appointment site). In short, Xiehe has morphed into an intimidating monstrosity that is far more trouble than it’s worth, and I have turned to other hospitals in the city for medical treatment.

A study in contrasts

The USA and China bear the distinction of having the worst health care systems in the world not attributable to national poverty. In both countries medicine is privatized, ensuring the perpetuation of illness and disease for the sake of monetary profit. This still applies even after the launching of Obamacare in the US and a similar national health insurance program recently in the PRC. Neither country’s systems are comprehensive but still require large outlays from the patient.

At the core of capitalist medicine is ideological mystification of these economics through the enshrinement of hospitals as temples and doctors as high priests. The body too is mystified, by being turned into a commodity that becomes profitable in the production of illness. The food industry benefits by accelerating illness with the toxic modern diet, and the medical and pharmaceutical industries benefit in turn from expensive regimes for restoring the body to health, or even better, to a perpetual state of sub-health, e.g. manageable conditions such as diabetes requiring permanent medical intervention (much as credit card companies prefer that people never completely pay off their debts).

At the same time that they are supposed to treat illness, hospitals spawn disease through well-known and documented unsanitary practices. It is common knowledge that most hospitals are filthy and hazardous to your health. Iatrogenic diseases (i.e. those caught in the hospital), notably Methicillin-resistant staphylococcus aureus, infects 100,000 and kills 20,000 in US hospitals and nursing homes each year, yet is known to be largely preventable with improved sanitation. China also admits to having a problem with hospital-borne MRSA. Meanwhile Norway, with its socialized and non-profit-driven medical system, prioritizing the elimination not the creation of disease, has succeeded in virtually stamping out MRSA.

Profiteering aside, there are other key differences between the US and Chinese medical systems. The Hippocratic Oath is not as entrenched in Chinese medicine. One result of this is widespread indifference, not to say callousness, toward the stricken and infirm. This is not always conscious or intentional but a natural result of a society with a massive population, set up to deal not with individuals but with people en masse. A kind of society-wide triage applies, with stark rules and few shades of gray. The population is well aware of this, and if Chinese people are good at saving money it’s with eventual family medical disasters in mind. Americans can always receive emergency treatment in any hospital without funds on hand; they’ll just be plunged into debt or financial disaster afterwards.

American doctors are highly paid and regarded as an elite. They cultivate this aura in turn and perform not just care or surgery; they perform for the patient. It’s a performance, and it’s the performance that sustains the aura: the doctor’s delayed entrance after the nurse’s preparations, the suspense, the dramatic appearance in the office, the diagnosis, the prognosis, the oracular pronouncement of deliverance or doom, and the absolute, unquestioning respect with which this information is received. What keeps up the faith in this system? In fact it’s been coming under attack with the Internet revolution. With so much information available and ordinary Americans cultivating their own medical expertise, doctors must contend with, and compete for, increasingly informed patients who shop around as discerning customers.

The Chinese, by contrast, have long distrusted doctors, just as they tend to distrust everyone in authority. They are far tougher customers than Americans and quite logically insist on results. They demand quality for such an expensive product, now approaching US prices and often coming out of their life savings. In recent years a terrible phenomenon has arisen in Chinese hospitals. When patients die, family and relatives converge on the hospital to threaten, assault or even kill the doctors and staff they deem responsible. Hospitals have had to hire armed guards and open back offices for quiet negotiations to resolve disputes and avoid publicity. However appalling this violence, it’s symptomatic of Chinese medicine today and the ultimate expression of despair at the absence of government oversight and regulation of the one institution where it’s most needed. It’s what happens when doctors routinely take bribes and over-prescribe medicine and procedures on a far greater scale than in the US. But for all the differences in their medical systems, the obvious solution for both countries is the same, and that is socialized medicine.

*     *     *

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