#financial planning being one of them; i hope they gave enough vaccines at work for that bonus

[autistic-shaiapouf]

Sitting at the very top floor of the hotel listening to the elevators as they move and there's something calming about it

[scarecoen]

Trigger warning ⚠️ domestic violence.

I've typed this story a million times so I'm just going to summarize as much as I can.

A few days ago I was assaulted by my partner's family members. And as I've mentioned, I've typed this a million times and I'm honestly just exhausted thinking about it, but we could use some help.

My partner has always had a transphobic family. (I don't have anyone but my dad, who's in no position to help anyone.)

Her mom used her disability against her and manipulated her into giving her MOST of her checks. She's abused the system and my girlfriend.

When I met Jackie, she was with a terrible biggot. Jackie had came out, and her mother conspired with an abusive long distance ex, to fly her here, to stage an "intervention" and stop my partner from transitioning.

It worked. For years.

I met Jackie here on tumblr, we became good, SECRET friends because she wasn't allowed to talk to anyone.

I told Jackie openly about my views regarding gender and how I myself, was not cis.

Eventually she told her partner about us playing games together, which she responded to by harassing me.

Jackie ended up spilling the beans to me, about her mom, about the ex, everything. I realized that she had been extremely isolated and controlled her whole life.

So I intervened.

I got the two of them to separate, which wasn't smooth because Jackie was scared. She had been with her abuser for 9 years at this point. She's never known anything else.

The ex moved back to her state, and I started seeing Jackie, although she was stuck at her mom's... who was trying to play innocent at this time.

Eventually, I kinda just came and picked her up, she stayed the night, she didn't want to go back home. And I can't blame her. The house wasn't only disgusting, her family microagressed her all the time and they would tell her to pretty much stay in a dark room all day.

Ofc I didn't bring her back.

During early quarantine, we had a lot of self reflection and she started distancing herself from her mother, coming around to holding her accountable for her horrible actions.

Her mom messaged her things like "Why won't you talk to me? It's like you're trying to punish us!" Ect, just every fucking manipulative thing she could say, without ever apologizing.

Unfortunately the place we were staying fell through when my best friend's ex husband decided he wants a divorce and decided to throw in some transphobic hatespeach towards me.

We were all looking for somewhere to go.

I'm sure you know where this is going but listen, she told us EVERYTHING we wanted to hear. She told us she's not hateful now, told us she would go to trans support groups, pride, said she's realized how much she loves Jackie and it's time to accept her- and look- we had NO WHERE TO GO. We have 2 cats and at the time, a car that has no a/c or functional locks. AND I have a chronic autoimmune condition that I recently started taking chemo meds for. (Methotrexate.)

I'm too sick to be on the street, and survive. I had to think about me, Jackie, Zoe, and Boops.

And Jackie wanted to go..

I told her we'd be cautious and try to get out asap.

Well, looking for places right when the housing market crashed really fucked us up. That- and because I had only just finally got approved for disability, means I was set back in life- and had no credit to my name. No credit= no place to live.

I had almost built enough, but things went down hill very quickly with her family. Which leads us to right now:

After weeks of microagressions, giving us breakthrough covid cases, yelling at us to clean other's messes, and forcing us and our cats to isolate in our room, many broken promises, and straight up transphobic hatespeach (because she promised to get vaccinated but then said nvm as soon as we moved in and she went on vacation and got covid and gave it to us, which nearly killed me--) she said not getting the vaccine "IS A CHOICE, JUST LIKE YOU BEING TRANS AND TAKING *gestures to my testosterone* THOSE DRUGS."

We just were avoiding each other while I desperately try to gather resources for us to get out, NOW.

Of course, that wasn't good enough, so when her step father messaged her in all caps about our cats having to stay in our room and "I WON'T FUCKING TELL YOU AGAIN" my partner had a breakdown..

Her mom had let her step dad talk to her like this her whole life, basically.

Out of desperation, we went to her sister for help, maybe hoping she'd give us a place to stay for two weeks while we sign off on the lease for our new apartment.

She pretended to want to help and even said... something fucking weird? She made the comment that I'm a good person and I'm so much like her own boyfriend, that it's "scary"...

A few hours later she came to the house. She talked nicely to us, to gain access to our bedroom.

Then she attacked me.

I called the police right before, and was on the phone with dispatch when she lunged at me because she was aggressively trying to MAKE Jackie go into a separate room WITHOUT ME and Jackie was saying no, BEGGING her to STOP.

I wasn't going to let her take Jackie into that room. She looked fucking crazy.

All of the family came into our room, her two sisters, her mom, and her cousin- When they heard yelling.

It was actually me telling her mom that she's a terrible mother, that triggered her sister to try and attack me- although I knew she was planning on trying to from the moment she came into our room.

And that was after her mom was screaming in my face that if I have something to say, say it now.

Dispatch heard everything and sent emt as well...

But the police stayed outside, talking to them for a WHILE before even asking for us.

Her cousin is the only one that would have stood up for me, saying her sister never should have tried to hit me. But he was in the room with Jackie, giving her support...

I faced the cops alone.

He already had "that look."

He shined a light into my eye, letting the family stay on the porch, throwing insults and just letting it happen. He asked me where I'm hurt, and before I could even show him the scratches on my arm, he said "how do I know YOU didn't put those there?"

I wanted to fucking die in that moment.

This is a conservative city.

No one has equality stickers here. No one flies gay flags. People here that are lgbt- they LEAVE.

This is EXACTLY WHY.

I said "well is there any reason I should tell you anything when, clearly, you're already bias?"

I looked at the emts. I looked at his partner. I looked at all the lights and people coming out of their houses-

And behind me was her family.

Her sister that assaulted me, was laughing about having work in the morning.

All of them were looking at me, with hate in their eyes.

He tried to feed me bullshit about "well if I'm taking someone to jail, there has to be proof."

He dismissed everything I attempted to say, until I just stared at the ground and he decided he did his job here.

I told him my whole fucking body hurts because I had 4 people fucking toss my 100lbs ass all over the fucking room, which was a mess that he refused to look at.

He said "I don't see bruises."

I SPAT "BRUISES TAKE TIME?"

He retorted IMMEDIATELY- "YOU'RE NOT EVEN RED."

I asked what about the dispatcher- she seemed concerned- to which he said "you see, sometimes when people call us- they scream and be dramatic- for a quicker response."

I asked what we could do while the two weeks go by for our new place, and he fucking said "I DONT KNOW. BARRICADE YOURSELF IN YOUR ROOM OR SOMETHING."

Needless to say, we are now safe, in a hotel and I've gotten in touch with a few lgbt organizations that are attempting to help us get justice.

Unfortunately because it's a holiday weekend, all we can do is wait right now.

Our first order of business is getting a protection order, so that we can retrieve the rest of our things without her sister trying to attack us again. (I say us because she kept jumping towards Jackie, like she was threatening to hit her.)

I've been so gaslit and victim blamed that I was too scared to go to the er, even though this all happened in the midst of a flare, possibly including my liver health.

There's so much more to this story, as I'm sure other trans people can relate.. unfortunately.

The emts reluctantly offered to take me to the er, but I was like "and leave my partner here with them?" And he just fucking shrugged dude.

I hate this city.

I want out so bad but unfortunately I've committed to a year, but at least it'll be *our* apartment.

We could NOT stay there for two more weeks. Her step dad is a violent offender that has attempted to murder a homeless prostitute over some fucking pocket change- and he has a GUN in the house.

This hotel might run us into a hole, despite it being the cheapest, shittiest hotel in town, it's still going to be about 700$ for ONE week.

To ADD INSULT TO INJURY, SOMEONE ATTEMPTED TO STEAL MY VEHICLE WHILE WE'VE BEEN STAYING HERE.

I'm feeling incredibly paranoid and unsafe, but I'm on anxiety meds now at least and its SORTA helping us cope (My partner and I have the same Dr and she gave her permission to have some.)

The organization BRAVO is trying to help us with a hotel voucher, but because of all the natural disasters, it's hard to find room in charity for people like us, which is fair enough. We aren't immediately on the street, and for that I'm incredibly thankful.

However, if you or anyone you know wish to help you can donate to venmo: kittyzibby. Or you could just signal boost this.

If you can't help, I understand. And IF YOU'RE STRUGGLING FINANCIALLY, don't worry about it, for real.

Right now I'm just scared we'll go into debt before getting the apartment settled in.

I will update on things once our case moves along more, and we were already considering turning to OF sexwork before all of this, so if there could be support that way, maybe we'll get that going once we get moved in. That way, I feel good about providing a service in return.

Thank you so much for sticking with us during all of this. And really- we're doing much better today. We've given each other pep talks, but we are still determined to start our lives together.

Her family was merely trying to scare me away from her, but I got my girl's name tatted on me for a reason.

I know I'm not the bad person here.

Every time Jackie is feeling more gender euphoric, and showing me her changes, and seeing her get more confident, the more I know that what I'm doing with and for her, is right.

I love her so much. And I will never abandon her, like they tried to get me to do.

Jackie is taking a break from some socials, but she's given me permission to talk about what's been happening.

She needs justice too.

I will update as much as I can, but seriously, I think we both just have a fire under our asses now.

Mentally, we're stronger than ever.

Thank you for reading. My heart really goes out to the rest of the queer community that have experienced or are going through similar things.

It's really made me realize why we need to stick together and fight this bigotry bullshit! 🏳️‍⚧️🏳️‍🌈

[gra-sonas]

Interesting interview with CW President Mark Pedowitz. Roswel, New Mexico is not mentioned, but he talks about programming decisions, straight to series orders, the next fall schedule etc. Another thing he mentions is, that he's happy that The CW will air a few more "family oriented" shows (like the Kung Fu and Walker reboots, and Superman & Lois). If you squint, RNM's very much a "(found) family oriented" show - with aliens. ;)

Pedowitz also mentions, that they have several slots to fill for the upcoming fall, and the 2022 spring schedule, but they haven't made all the decisions yet. While we might not hear about a S4 renewal very soon, this gives me a fairly good feeling tbh. RNM's an established show, it's comparatively "cheap" to make, they have great tax incentives in New Mexico, and the show is doing overall well enough in ratings and international sales.

—————————————————————————————

Mark Pedowitz, broadcast's longest-tenured chief, has no regrets about delaying the start of The CW's fall season.

His network (like Fox), made the decision last summer to wait until the new year to bring back scripted originals like Riverdale and All American. The late start afforded productions more time to get used to filming during a pandemic, where episodes take longer (and cost more) to complete. It also.

While the January fall launch gives the network a backlog of originals to air without interruption (provided the pandemic doesn't have other plans), it also delayed decisions like the network's traditional mid-January slate of early renewals.

Now, as The CW prepares to formally launch its fall season on Sunday with the returns of Batwoman and All American, Pedowitz talks with The Hollywood Reporter about how the network is plotting a return to business as usual, including more straight to series orders, developing shows with heart and, yes, the future of all things DC.

Let's pretend we're at TCA: When will you bring Supernatural back?

If they boys want to come back, we're ready to have them. (Laughing.)

The CW traditionally hands out early renewals during this time of year. Where are you in those conversations, especially since your season doesn't formally start until Sunday with Batwoman.

I'm just getting into those discussions. I came from a studio background and understand the importance of early pickups — it allows for better preparation. We're a few weeks away but I need to finish up some internal discussions.

ABC, NBC and CBS all returned originals late last year. In hindsight, any regrets holding the season start to January

No. Once we said it, we felt it was the right thing to do. It would have been too patchworky. At this point, it gets longer and longer and you're waiting to get back into some form of what's your finished product going to look like? I have no regrets. I just wish it didn't take this long to happen.

How much has The CW's late start to the season — originals return next starting Sunday night — impacted the way you conduct business, both in terms of renewals and the negotiations for pilot orders, etc.?

We did this strategically and made choice in the summer because we were concerned with misleading affiliates, the consumer and the ad sales community that we were going to have a fall schedule in the fall and felt that wasn't the right thing. We found some successes with some of the acquisitions, like Stargirl, Coroner and World's Funniest Animals. Some of those are good linear, a lot of them were great on digital. Our digital presence was kept alive because of that. That said, our fall had Supernatural. And once that came back, we were doing [ratings] numbers we were doing pre-pandemic.

We are interested in seeing how people react. It's not just a covid issue right now; it's also the uncertainty in the country with news being as much of a viewing choice as anything else. We're going to have to see how it all plays. We're getting a little colder of a start than we would have if we rolled out of summer. On a digital basis, we're fine. On a linear basis, it's gotten harder.  On the development basis, nothing has really changed. I think straight to series [orders] will be done again this year — just for financial purposes so people can get going as quickly as possible — by the end of January. That could change because the surge could change. But there is a bit more flexibility to it. We're still on the same schedule: we have to talk to advertisers in some form in May about what things look like for the following fall. We're hoping that the following fall is closer to a normalized fall — like 2019 was. Do I think it will be completely that way? No. Do I think it will be much more that than not that? Yes.

So, you'll be focused largely on straight to series orders instead of pilot pickups this season?

We haven't seen a lot of development yet. Lost Boys and Maverick [ordered to pilot last year], because of what occurred, are back in contention as development, not because they got picked up to pilot last year. They're in the mix with many other things, including dramas from Ava DuVernay, Black Lightning spinoff Painkiller, Wonder Girl, PowerPuff Girls, The 4400. The scripts are coming in slowly. Right now, I've seen just a handful of scripts and I'm waiting for others to come in so I can make some decisions. They're in contention for how we pick up pilots or direct to series.

Last year, you went straight to series on Superman & Lois and Walker largely out of concerns that there could be a WGA strike. Why is this an attractive model for some development this year?

A lot of is dependent upon what we're dealing with in terms of production needs with ongoing series in a sense. The other is what's the economic impact. Bypassing pilots is short-term less money than going straight to series. We look at the economic impact and if we believe enough in these shows and that will determine the decision.

With two veteran shows — Supergirl and Black Lightning — ending, how much more room on the schedule do you anticipate you'll have? You're making straight to series decisions based on a slate that will have just gotten under way.

We'll have space for three or four shows for next season, 2021-22. We're sorry to see Supergirl and Black Lightning go, but we're happy to have Naomi, Wonder Girl and Painkiller in the hopper right now. From The CW-DC/Arrow-verse — whatever we're calling it these days! — I think we'll be OK for the next generation. The Flash is new leader with Arrow gone and we're hoping Superman & Lois and Batwoman step up there for a new grouping of shows.

How much more life is left in veterans like Flash and Legends as you develop the next wave of the Arrow-verse? Especially when you have Greg Berlanti doing a big-budget Green Lantern and DC world at HBO Max and J.J. Abrams doing Justice League Dark for the streamer?

And they have Matt Reeves' Gotham PD there, too. It always makes me feel good when we're copied. (Laughing.) There's a lot of life left. Greg and I speak quite frequently. I'm not that concerned.   You recently passed on Green Arrow and the Canaries. Why? Timing. We couldn't quite figure out a model similar to Stargirl and couldn't quite get there. We were hoping to have it start at HBO Max and take a second run on The CW, but we couldn't figure out how to do it and couldn't make it all work.   Last year's pilots Lost Boys and Maverick are back in the development stage. What's the status of The 100 prequel?The 100 prequel is still in discussions at the studio level. I'd like to see it happen. I'm comfortable with where the prequel spinoff episode we did this past season. It's not a pilot; the earliest that would happen would be probably summer 2022, if that happens. We may end up deciding that we can't put the pieces together and it won't happen.

Speaking of the studio level, Warner Bros. is in the midst of a massive change as Channing Dungey is replacing Peter Roth. How does the changeover at Warners — which co-owns The CW alongside CBS Studios — impact the network? What kind of conversations have you had with Channing about their content pipeline since Warners is your main supplier?

Peter and I had remarkable partnership and relationship, and that will be missed. Channing worked with me when I ran ABC Studios and we've known each other for a long time. She's very supportive of The CW and the shows that go on The CW. There are shows she'd like to keep there and get on the air there. Obviously, her priorities may be a little different than Peter's. We are all working toward the same goal.

How has the pandemic and our current state of the world changed the types of programs you're looking to make? Can you do a show like Maverick, set on a college campus, during a pandemic? Do you still make dystopian stuff, especially if it's expensive?

Maverick is still in contention. I just had this conversation with our development team. I've come to the point right now about hope. About safe havens and a place where you can just ease your tension a little bit. One of the nice things about Superman & Lois, Walker and Kung Fu is at the end of the day — despite all the superhero/genre and Texas Ranger stuff — all three shows are about family, which is an important aspect going forward. You'll see Superman in a way you've never seen him before. And you'll see Jared Padalecki in a way you've never seen before. After watching all eight of Wentworth, I switched to Bridgerton because I wanted something light and fluffy. And I found Ted Lasso a worthy successor to Schitt's Creek — it gave me a hug and made me feel good. It made me remember that the human condition is not always bleak. That's where my head's at these days and I'm hoping development is more hopeful than it is dark and dismal.

Have you considered keeping production on your scripted shows going through the summer given the current covid surge that's happening this winter and the uncertainty in terms of vaccinations and new, more contagious strains? 

We work with the studios on episodic orders and when the shows would end, when they can revert back to a normalized schedule — some can do more easily than others — so we could be there for next October with a more normal schedule. We've sat with the studios and our production partners and have figured this out. Barring catastrophe, we think we're in good shape.

The CW is a joint venture between Warner Bros. and CBS Studios. Since both studios have prioritized their own studios, how much longer does it make sense for them to operate a linear network?

That's a question for them. for the moment, both parent companies are happy with how this is set up. They recognize the value of The CW brand for selling their shows in digital aftermarket.

Interview edited for length and clarity.

[rainey-staerie-daize]

So far, this’s been a weird bad week.

On Sunday, I awoke to cinnamon rolls, strawberries, and bagels, which is unusual in our household. We usually have cereal, but I was fine with this change. I love cinnamon rolls. I thought this was gonna be the only oddity of that day, but I was wrong.

Skye said she was gonna stay home during the littles’ visit, so I got hopeful that I could have a heart-to-heart with Mom about the previous week in the car, but she ended up coming with because I was and she didn’t want to be home alone. And then, Kare was with us too, because she didn’t want to go, so we had her with us for two hours. But, oh! Not two hours, but one, because without Kare, Xan only wanted to spend one hour with their dad.

So, instead of maybe stopping at the store or something, and counting off all the reasons I’ve been upset with my mother, we took a drive for an hour with my sisters. For the first time ever, I turned the other way in the car, hoping Mom got the hint that something was up. After a while of silence, she asked Kare how she was doing, as she usually does when it’s been silent for a while, and then asked me the same thing a minute later. I gave a noncommittal hum, not wanting to talk in that moment with almost everyone in the car.

Before picking up Xan, she went through the Starbucks drive-through to get us each something, so I turned the right way to be able to drink my matcha pineapple drink, but I was still not very happy. Refreshers and fraps can’t fix the hole in my heart where love should go.

After getting Xan, we went to Ross for a new outfit or two each because it’s getting hot out here and Mom has stimulus money right now. I usually love shopping, but considering that I was already upset, Mom previously promised an individual “date” day with each of us for this, I didn’t have my glasses or phone that day, and I like to take my time, I wasn’t having a good time. I found cute items that were too small for me, and couldn’t take pics because I didn’t bring my phone, and I was the last one of the family to be perusing the racks. I HATE to be the one everyone’s waiting on.

And then to top it all off, Mom complained in the car that she “spent way too much money.” I already have a nagging guilt in my subconscious soul whenever I’ve been done shopping the last few times, even when spending my own money. I really didn’t need to hear that I’m actually being a burden on someone, either time-wise or financially.

Holy shit, I need to take a minute.

Anyway, we came home, and everyone went straight to trying everything on. Which makes me anxious, because we just got these clothes, and Mom usually wipes things down or washes them before we use them. Wondered for a few if I was being paranoid, before concluding that I’m not and Mom’s just slipping at this game.

Then Mom started talking about chores we need to get done, and that the garage is getting cleaned out today. Now, she’s said this a lot, so I never know when she’s actually gonna get serious, but apparently, she actually meant it.

I like to clean by myself, preferably when everyone’s asleep or gone, because I know damn well I take to long, and I don’t want the ridicule. Big problem with that is the fact that the anxiety from the possible judgement keeps me from actually starting, so I end up never starting and it never gets done. And Mom was is sick of my shit. Many of the boxes and bags of laundry in the garage are mine.

So, as I was sitting in the kitchen trying to enjoy the ice cream Mom said we could all have, I was trying not to panic when Skye was going through the garage for stuff to bring in and go through. Mom mentioned that she was gonna “force inspiration to clean” onto me, and I told her that’s not how that works.”

Luckily, she found a couple bags of toys to go through first, and I sat and watched, trying to relax so I’d stop feeling sick to my stomach. I’m trying not to feel sick as I type this all, but I gotta let my feelings out somewhere.

Eventually, she brought in a bag of my stuff. I looked at a couple items, and determined it was a bag I’d already gone through a few months ago. It was only in the garage again because I hadn’t washed and put it away yet. So far, so good. Another bag, and I was able to throw some things away without any second guessing. Eventually, I didn’t feel so sick anymore, and was in productive mode.

At some point, Skye asked if she should bring in something that wasn’t clothes, and I explained quietly that I’ve had enough mentally. “Please don’t make me switch tasks right now.” I’m so glad, that at age 20, I know I’m autistic, read up on it a ton, and now have the tools I need to communicate what’s going on in my head.

Skye understood, and brought in more clothes. I’m also so glad to have her as a sister. Mom would’ve seen it as making excuses, which is why I tried not to be loud enough for her to hear. I was in a zone, doing what she wanted (and I needed) for once, and I didn’t need her to break it by yelling.

I set aside the things that weren’t mine to go through, and I got it done. Since I still had quite a lot, I decided to go through everything more selectively at another time, on my own time. We’ll see how that goes.

Had dinner, and I didn’t feel like eating as much as I usually do, and said this to Mom. Told her about how the day went nothing like how I’d planned, and she seemed to finally recognise some depression in me, and offered to have that talk I wanted that night or the next day. After dinner, I chilled for a while with the Gravity Falls tag (pretty sure y’all’ve noticed) in the bathroom, because it’s the one private room of the house and I wanted to be alone, and when I came out, everyone was sleeping and Mom was cleaning. She was spraying everything with Febreze, and then vacuumed after a few, and told me to check my slippers to see if they’re dirty before walking on the carpets. I find this a bit absurd, seeing as how Mom is the one who gets the floors dirty with her shoes (FR, she’s the only one of us that leaves visible shoe prints inside), and I wear slippers specifically so I don’t have to keep washing my feet all the damn time. But not wanting an argument, I complied, and took off my slippers to sit at the desk with the laptop.

The plan was to finally catch up on my school work, but after Mom got on me about the dog being neglected, I simply didn’t have the spoons, and looked up pics of Ford’s futuristic gun. Eventually started reading Gravity Falls: Lost Legends on the purple game phone. Not very productive, I know, but I knew I didn’t have actual class the next day, and I’m normally very responsible with the dog. I’ve only been neglecting her as a bit of a social experiment to see if anybody would notice that the one person who cares for her hasn’t been. Don’t worry, I gave her food and water after a while, but I left the red blanket covered in Kare’s piss over the crate, because if Mom thinks she knows best and wants to put a dirty-ass blanket over the crate, who am I to remove it?

Fucking bitch.

Anyway, after she went to sleep, the living room felt like the Twilight Zone. It had the vibe of being freshly steam-cleaned, despite not being cleaned at all, I felt like I couldn’t lay down anywhere because dirty laundry had touched my leg earlier and I didn’t feel like showering yet, and everyone was asleep but me. Two or three lights were on but I shut them off to help calm my mind a bit. Worked a bit, and I continued reading until the next morning. I heard Mom’s alarm for Xan’s school day start going off, and not wanting to interact with her, I laid down to sleep, letting fate decide if she gets up on time or not. Skye says she didn’t, and Xan ended up not going to school. Oh well. Not my problem.

Oy, she would think I’m such a selfish bitch if she read that, but I honestly don’t care. I half hope she stumbles across this blog just so she finally knows what I’m thinking all the damn time. Stars know that we never did have that talk. In fact, when I made a comment before she went to sleep on Sunday that I’m aweful at this whole “being a human thing,” she accused me of just trying to get sympathy, and “stop the whole ‘woe is me’ bullshit.”

Oy, so I’m amazing, I guess? What do you want me to say? Nothing?? I mean, I guess that’s correct. I would finally stop bugging her with my too-loud voice. I try to moderate my volume, I really do, but sometimes I forget, or I’m being louder than I think I am.

Yesterday, I slept a lot of the day, woke up to take an exam, and came out of my room to find all but one piece of the pineapple Mom got gone. Not only did everyone save me only a single cube, it was so sweet and good, and I’m not sure I did so well on my exam. Mom said the littles’ scarfed it all down in minutes, and that it wasn’t even that good because the enzymes burned their tongues, but I don’t feel bad for them. They wouldn’t have gotten burned so bad if they had saved some for Skye and I. She was still sleeping at the time. I also spotted the only pineapple juice in Kare’s Starbucks cup from the day before, but when I took a sip (because she often wastes food, she won’t miss it), I discovered it was watered down. Ugh.

That night, last night, as I stayed up late reading fan-made Gravity Falls comics, I tried to stay as silent as possible. My laughter is often loud, and I was finally having a good time. I didn’t need Mom waking up to scold me with the whole “I work graveyard, and I just got vaccinated! Why can’t I ever sleep?!”

I think I did a pretty great job of staying quiet for once, but at some point, she called my name, which startled me a bit. I went to her room to see what was up, but after I called back and got no response, I determined that she just called my name in her sleep. Whew.

And now, I’m sitting at the kitchen table, typing away, still being silent. I’ll have a good time with Skye when Mom’s not around. Mom doesn’t deserve to hear my laughter anymore if she doesn’t want it so bad. She was watching late-night comedy when I was typing the first part of this post, but at some point, she got up, and I quickly-but-casually switched tabs to the music I was listening to to read the comments until she left from behind me again. I do want to talk about all of this with her eventually, but I really don’t tonight, and she sometimes reads over my shoulder if it’s easy for her to do so.

I hope she’s getting ready for work right now, and she won’t be able to get an Early Out. I’d love for the anxiety of her randomly crashing my vibes to be gone. Maybe (but probably not) I’ll clean, maybe I’ll read some more in the dark. Don’t know yet.

[keywestlou]

SIZABLE PORTION OF BIG SUR WASHED AWAY

America has been blessed with many beautiful nature scenes. One is Big Sur in California. Officiously known as California Highway 1.

Many years ago, I was in the area of Big Sur to play golf at Pebble Beach. My tee time one of the days was in the afternoon. I decided to see the Big Sur I had heard so much about.

Rented a car and was on my way.

The coast of California near San Francisco and running through Carmel is one huge cliff. Not as high as those in Santorini. High enough, however. At least 1,500 to 2,000 feet up.

A highway was carved out which runs sometimes on top of the cliff and other times a road has been cut into the side of the cliff.

Below the Pacific Ocean! Majestic waves pounding the base of the cliff.

Majestic! Beautiful! The only way to describe Big Sur.

I was sorry I was alone. The drive is one to be shared with someone with whom you have a close attachment. Such is the mood!

This morning’s news carries the sad story that a significant portion of the highway has been washed away by a winter storm. Obviously that portion of the highway will be closed till repaired. Could take quite a while.

One last observation. There are very few homes along the way. Only nature in all its pristine glory.

Joe Manchin is Governor of West Virginia. A Democrat who seems over the years to have voted more Republican than Democrat.

Can’t blame him. West Virginia a deeply Republican state. Coal mining a major industry.

It was announced yesterday that West Virginia was a “vaccine success” story. Eighty five percent of its doses requirement received and used. Yes, 85 percent of West Virginia has been vaccinated.

Only North Dakota has done better.

Why West Virginia and North Dakota can do it and the other 48 states still struggling to get going, I do not understand.

The numbers reported were by the CDC and not West Virginia itself.

A civil servant in charge of the program said it was the result of “creativity” and “innovation.” West Virginia studied what was happening in the rest of the U.S. and came up with their own plan.

The State did not activate the federal partnership with CVS and Walgreens. Instead went it alone.

West Virginia is more rural than big city. The State went to the small independent drug stores. Many mom and pop operations. State officials thought such would prove productive. Obviously, they were correct.

The small drug stores went to the people’s homes and farms. They did not wait for them to come to town for a shot.

Many persons live 40-50 miles away from the big cities and chain drug stores.

One story told involves a mom and pop type operation with a couple of employees. They stored the vaccine in a special refrigerator in their home kitchen. Six every morning they were at their kitchen table figuring where to go that day and arranging the vaccines to be carried.

It all worked! God bless Joe Manchin and the people of West Virginia!

I would like Florida’s Governor DeSantis to plan better as Joe Manchin did. Every DeSantis planned program thus far has failed. Looks good up front and then peters out.

Going to run Day 6…..Greece the First Time at this point. Then return to some other news items I wish to share.

  DAY 6…..Greece The First Time

Posted on June 2, 2012 by Key West Lou

Greece is a time bomb waiting to explode.

The people are unhappy. The financial crisis is choking them.

Economics is the topic of conversation everyday. Expressed with increased vehemence each day.

Riots around the corner. Protests already. The situation a tinderbox ready to ignite.

I was on my way to the Metro Underground beneath the plaza in front of Parliament yesterday. Thousands of people walk the plaza hourly. In one corner near the entrance to the Metro, several young people were carrying signs. One was talking into a loudspeaker.

Speaking Greek, of course. I neither speak nor understand the language.

About 50 persons milling about listening. I mingled in the crowd. I was able to pick up the gist of the protest from comments made by onlookers. Economics. The euro.

Listeners aroused. The name Merkle caused several to spit on the ground.

Recently, Greece had an election. Neither the left nor right obtained enough votes to control the government. So the Greek Parliament is floating along. The country in limbo.

A new election is scheduled some time in June.

Italy’s former Prime Minster Berlusconi announced yesterday that unless Germany backed off the euro, Italy should return to the lira. Germany appears the only European nation benefiting from the euro. The Greeks and Italians dislike the Germans. They feel Germany is being hard ass about doing something corrective regarding the economy. Whatever might be done would not be to the financial benefit of Germany.

Beware. I sense bad days ahead. Keep in mind that we live in a global world. Whatever happens in Greece and elsewhere affects us in the United States.

I spent 3 hours doing yesterday’s blog. I sat in one position and typed for the three hours. When I finished, my legs from my knees to my ankles were full of fluid. I went back to my room, took a fluid pill and lay on the bed three hours till the problem was relieved. Today I am getting up and moving about on occasion as I write.

I took the Metro Underground. It is a subway. I have not been on a subway since my senior year in college in New York City in 1957.

The purpose of taking the Metro was to visit Acropolis and the Parthenon. Way up a hill. Better to ride than to walk. One stop on the Metro.

A problem. The Metro Acropolis stop was still at least a mile from the entrance. An uphill walk. At a constant 30 degree angle. In the boiling sun.

Not my cup of tea. I had to stop not several times, but many times to sit and rest. As I sat, many passed me by going to the top. Many  older than I. Some obviously infirmed. While Louis sat, they marched.

The first part of the return trip was a problem also. The initial path down was of marble. Huge irregular blocks. Slippery. Small cuts in the marble to minimize the sliding factor. I slid, did not fall. It was not easy.

The trip was worth it. I was a part of history during the time I was on top. Acropolis, the Parthenon and other smaller temples. The most stimulating factor for me was the realization that all I saw was constructed BEFORE Christ. Way before.

Acropolis a temple to the Gods. The most exciting feature of the Parthenon the columns.

The smaller temples had columns also. However, they were copies. Some time back, there was a violent earthquake. The columns could not handle the movement. To protect them from a future abuse by nature, they were removed and replaced. The originals sit in a museum at a point down the hill.

Two generationally different fat cats responsible for much of what has been done. Pericles back in the 400s BC. The Rockefeller Foundation in recent times.

All the buildings are fragile. Thousands of years old. Modern man is constantly working to preserve that which was. There are scaffolds and cranes every where.

There had to be a topping on the cake after such a glorious walk back in history. It came in the evening. Dinner at Dionysus Restaurant.

Dionysus sits at the foot of the historical mountain. About a mile away. It is a huge outdoor restaurant. Top self. Great lamb. Greater view. Expensive. Worth it.

There in front of my eyes on top of the hill sat the Acropolis and Parthenon. All brightly lite. Awe inspiring. The viewing emotional.

Traditionally Dionysus was the God of the grape harvest. He was also known as Bacchus. Party boy! Festivals galore!

Did I sleep last night? Finally! The first full night’s sleep since starting this trip. I hope the jet lag is behind me.

Today is my last in Athens. Tomorrow I leave for Santorini. I still have not danced nor thrown dishes around. Hopefully tonight. There is a little Zorba in each of us.

Yesterday was Ally’s birthday. Seven years old. I forgot. I will Skype her later and make up for it. I selected a birthday gift for her before I left and gave it to her. So I am only half bad in forgetting.

I know not what today holds. Whatever, it will be good. I am in a place where it cannot be bad. And tonight….hopefully dancing and dish breaking.

Enjoy your day!

Back to today’s news.

Trump continues to have lawyer problems. Big ones! No one wants to represent him in the Impeachment trial. First Giuliani and some others withdrew or could not accept the responsibility for various reasons. A new team of 5 came on board.

The five lawyers withdrew with the trial scheduled to begin 10 days from today. The reason was a difference of opinion as to how the trial should be handled.

Trump insisted election fraud be the top item. His attorney’s disagreed. The trial should surround impeachment issues and not whether Trump was elected. Sixty one courts had already shot Trump down on that issue.

I admire the attorneys for withdrawing. A doctor does not let the patient tell him how to do the brain surgery surgery he is facing. So too with the attorney-client situation. A competent attorney would do as the 5 attorneys did. My way or the highway.

L. Lin Wood is a Georgia attorney who brought several election fraud conspiracy cases to court. Each wherein he represented Trump in one fashion or another.

The Georgia Bar Association has now entered upon the scene.The  Bar has asked Wood to undergo a mental health evaluation. Lin has refused. Refusal could mean suspension or disbarment.

Lin has opted to fight. He has taken the position he did nothing wrong, only exercised his Constitutional right to free speech.

Amazing isn’t it how many of those who have tried to help Trump eventually end up behind the eight ball.

What happened to the Republican House and Senate members who feared for their lives on January 6, who hid under tables and benches behind locked doors, etc.

With the Trump impeachment trial around the corner, their tune has changed. Poor Donald! He didn’t tell the demonstrators to do bad, etc.

Whores one and all!

January 6 reminds me of the Reichstag fire in Germany on February 27, 1933. Hitler inspired. The fire solidified the establishment of Nazi Germany. Hitler’s government became entrenched.

The U.S. is not yet entrenched in any movement opposite to what it has been for many years. However, it could be moving that way. People on both sides are aroused.

Sunday, oh Sunday! Will my home quarantine ever end? Some days I think it is getting to me.

Enjoy your Sunday!

  SIZABLE PORTION OF BIG SUR WASHED AWAY was originally published on Key West Lou

[a-polite-melody]

A couple of people have suggested I set up a way to donate to help with Melody’s medical stuff that’s going on.

I’m not exactly comfortable doing that because we’re not sure what’s going to happen moving forward. Basically, I might start trying to get donations for the medical treatment we have planned, but find out that we can’t go forward with that or with very much at all and end up needing to refund most of what people had donated. And on top of that my dad made me aware that he put away money over Melody’s life in the event that she would need medical treatment. While what he had put away may not be enough to cover everything we need for however long she has left, it’s certainly a start and there isn’t as much financial worry as I would have thought.

I didn’t go over what exactly happened at the vet because I was so distressed that night, but I’ll do that now to give you all an idea of why things are a little complicated moving forward. Actually, I’ll give a full account of everything so far under the cut.

I’ll put a tl;dr up here...

tl;dr I’m not going to put up any kind of donations thing for Melody. She’s been through a lot over the week, and she may not have a ton of time left, but even if things go the most hopeful route, we’ll probably scrape by with what we have. I do very much appreciate everyone caring so much for Melody - the best dog I ever could have asked for.

However, if you’re still feeling generous, there is a family and a dog that need your help. I wanted to donate to them, but because of my money going toward school and my own dog, I can’t. Right now @vaspider has a youcaring up for Kusto [x]. If you do have some spare change and want to make a difference, please donate to them. I’ve been made aware that my family can cover what Melody needs, even if it is very tight, but these people need your help to keep their dog as comfortable as possible for the rest of his life (yes, it is a hospice plan).

A quick quote from vaspider’s byf:

“Kusto (SmallDog) is terminally ill. Please don’t send me messages of support that require responses. He’s 14. It’s fucking me up. I don’t have the energy to respond to those messages. I can feel that you are sad about my dog, and I appreciate it. Genuinely. I just can’t talk about it right now.”

So be sure to keep your support to things that don’t require a response.

Now on to Melody.

From August 4th to August 8th my dad, my uncle, and Melody were up at the family cottage (I was at my mom’s). According to my dad, everything seemed fine there. When they got home in the evening of August 8th, Melody didn’t eat, but it isn’t too unusual for her to skip a meal after coming home from the cottage. My dad didn’t worry about it and left the food bowl down for her overnight, expecting the food to be eaten by the time he got up for work the next morning like it usually is in these situations.

When my dad woke up the next morning (August 9th) he checked the food dish and none of it had been eaten. He thought that maybe this was Melody being stressed from travel longer than usual because of her age, but he wanted to get something into her stomach, so he tried giving her one of the hard treats she likes. Melody took it, bit into it, yelped, and spat everything out. He had to get to work, but once he was there he called me about what had happened, and said he’d try to get a vet appointment to look at her teeth. The earliest he could get was August 14th, so that’s what he booked. That night when he got home he gave Melody some cheese, bread, and lunch meat because they were soft and easy for her to chew, and she needed to eat something.

On August 10th my dad picked me up from my mom’s while he was coming home from work because I was going to stay with him for the next while. When we got home and let Melody out I noticed that her right eye looked strange. I took a closer look and realized it was nearly swollen nearly shut. My dad called the vet and asked if there was any way we could get in that night, but there were no openings. Rather than going straight to an emergency clinic (because those are extremely expensive) we called other vets in the area and we found one that could take us about an hour from when we called, though they had to get their vet to come in from their other practice.

We got Melody to the vet, and when the vet came in he asked if there was any way for either my dad or I to open her mouth for him to take a look at her teeth, since over the phone we expressed that she was not very good with being handled by strangers. We both said no. My dad can’t because Melody won’t let him, and while on a good day I can pull back her lips, because she was in pain I said that I wouldn’t be able to. So the only way to see inside her mouth was to sedate her.

They did a medium-low dose of the sedative into Melody’s back while I kept her head busy with cheese. The vet left for about twenty minutes, and when he came back to check on how she was doing, Melody was still wide awake and pacing around the room. He said they’d have to do an IV injection this time to be sure it knocked her out, and to do that they’d need to muzzle her. I asked if I could try muzzling her before we had someone try to force it on her face, they said yes, and I got it on her no problem with the help of some cheese. They took her into the back to do the second injection, and when they brought her back in she was already almost out.

The vet checked her mouth and felt around the eye and said he felt no abscesses or tumours or the like. So the problem was most likely that a couple of her back teeth in the right side of her mouth were infected and since the roots of those teeth go up near the eye that's what caused the swelling. He wanted to do blood work on her to see if the infection had spread to her bloodstream, so he did that, as well as an injection of an antibiotic, a pain killer, and a rabies vaccine since she was pretty much due for the vaccine at this point, so why not do that as well, right?

We were given antibiotic pills, painkiller pills, and anti inflammatory eye drops, they gave Melody the reversal for the sedative, and once she was able to walk we were sent on our way, saying that in a day they’d call about the blood work, and in a couple weeks they would probably be able to put her on anesthetic and remove the infected teeth.

Melody wasn't right for the rest of that night. She was woozy and not all there. She fell a couple of times because her back legs completely slid out from under her. I stayed up and checked on her every hour or so that night to make sure she kept breathing.

The next morning all was well. We soaked her food in water until it was mushy and she wolfed it all down! The vet called about the blood work and said the infection was in her bloodstream, so she needed to take another antibiotic as well. They also discovered she was in the beginning stages of kidney failure, which could likely be treated by simply switching her over to a kidney support food for now.

Things started getting better. Melody was taking pills fine, and while the eye drops were a struggle, her eye was looking back to normal. It was obvious her mouth was still bugging her, but that would only be until we ran the course of antibiotics and could have her mouth be operated on.

Tuesday morning (August 9th) I got up and started gearing up to go to work. I tried giving Melody her pills like normal - shove it in a cube of cheese, give her the cube, she’d grab it and scarf it - but unlike normal she very gently took the end of the cheese in her front teeth and tried to work the cheese further back into her mouth. She tried a couple times then spit the cheese wrapped pill back out. I tried again, and no luck. I tried feeding her other things, and every time she’d only take the very edge and try to get it further back into her mouth from there. I watched her panting and she would only open her mouth a very small amount. I called the vet and they wanted to get her in for X-rays on her jaw.

Once both my dad and I were off work we brought her in. She was doing better than she had been that morning, but she still wasn’t wanting to chew. She was sedated again for the X-rays. My dad and I were eventually brought back to the X-ray room to be shown the images. Her jaw looked pretty much normal, though she did have a touch of arthritis in the right joint. He then said he did full body X-rays, and switched to an image of her chest. He pointed out a mass up near her lungs and said that it was a tumour. At this point it’s small enough that it isn’t pressing against her lungs or heart, but we don’t know when it started or how fast it’s growing.

Knowing there’s a tumour in her chest is terrifying, not just because, you know, there’s a tumour, but because it also complicates putting her on anesthetic to have the teeth pulled. If the tumour grows very much by the next time we have an appointment (August 29th, the day before Melody’s 15th birthday) it will be too dangerous to put her on anesthetic because the tumour may interfere with her breathing or heartbeat.

So right now we don’t know what we can do. If the tumour doesn’t grow or only grows a small bit we’re going to try getting the teeth pulled. Of course there’s the problem that she’s very old, so being on anesthetic is already dangerous, and there’s no guarantee that she will be able to come back out of it, even under the best circumstances. If the tumour does grow enough that getting the teeth pulled would be too dangerous, we’ll likely start giving her a more powerful painkiller and just try to keep her happy and comfortable for however much longer she has or until the pain becomes too much for her.

I’ll probably post semi-regular updates on Melody for as long as I can to keep anyone who wants to know how she’s doing... updated on that I guess.

[waywardranchanimalsanctuary-blog]

What do you do when the system fails?

There are a few things that keep rescuers up at night. At the top of my personal list of worries is the current status of our adopted animals. Are the adopters providing the necessary medical and behavior care? Have the animals adjusted well to their new home? Are they loved? Does the family ever think about returning the animal to us? Over the past 2 1/2 years of running Wayward Ranch and the years I worked for other shelters in the past, there are a handful of animals I worry about in their homes from time to time. Maybe the dog was difficult in the shelter environment, and I worry they may misbehave in their new home. Perhaps the adopters haven’t been in touch with us or given us many details about the animal since adoption, and I worry about whether they are hiding something. I could rattle off a list of 10 animals right now that cross my mind, but if you had asked me three weeks ago, Hercules never would have been on that list. 

Above: Hercules at four months old the day he was rescued

When I first saw Hercules two years ago, he was just a four month old puppy listed on Craigslist. His family had bought him from a friend that had a litter of Dogo Argentino/Pit Bull mix puppies. They brought him home at just three weeks old, way too young for him to be separated from his mom and litter mates. After hiding him in their apartment for three months, their landlord caught them and they were forced to give him away. Instead of allowing this under-socialized, un-neutered, and un-vaccinated bully breed puppy to end up with a potentially devastating fate, as we have seen many times for dogs given away online, we stepped in to rescue him. 

Hercules became part of our Early Intervention Program. The goal of this program is to find bully breed puppies that are between 1 week - 6 months old and in high-risk situations (posted online for free or for sale at a low price in areas known for dog fighting), and fully vet and socialize them prior to adoption. We want to create positive bully breed ambassadors who grow up living with other dogs, cats, and/or kids so they can show what wonderful dogs well-socialized bully breeds can be. Hercules was fully vetted, microchipped, neutered and vaccinated and then brought to his foster home where he lived with cats and a young child. He was also socialized with other dogs at the dog park. We were especially glad to have found him because he had spent some of the most important months of his social development hidden away in an apartment without any other animals or people other than his owners. He was anxious and timid at first, in a way that could have developed into fear aggression as he grew older, but as he met more animals and people his confidence grew and he became a very social and sweet dog, a true success story of our Early Intervention Program. 

One month after Hercules arrived, we received a stellar application for him. An upstate NY firefighter who owned a home with a big, fully fenced in yard. He had owned dogs in the past, had a great vet reference, and had multiple wonderful personal references. We did what we call a “virtual home visit” since he was five hours from us, and were able to see the inside and outside of his home. He had already budgeted financially for a new dog and had a plan for continuing the training and socialization we had begun. He assured us that his fellow firefighters all had dogs available for play dates and it was likely Hercules could even come to work with him on some days. After emailing back and forth and multiple phone conversations, we set up a day and time to meet the adopter halfway between his home and our rescue. He spent over an hour there with us, learning about Hercules’ needs and walking him with us. He was kind, gentle and well spoken and Hercules bonded to him instantly. The adoption became officially and we wished Herc well as he headed to his forever home…or so we thought. 

Above: A photo update of Hercules in his home, one year post adoption

Over the past two years, we have heard from the adopter multiple times. He assured us Herc was a great dog, doing wonderfully with his training and socialization. He sent us photos of Hercules playing, sleeping, cuddling, and getting a bath; all signs of a happy and well-adjusted dog. We try to check in with our adopters at one week, three months, six months, and one year post adoption. After the one year mark we simply check in yearly to make sure all is well and offer advice or help any way we can. Some adopters are harder to reach than others and when we don’t immediately get a response, I always tend to worry that something may be wrong. Of course, once we are able to connect with adopters, my concerns disappear when we hear how well the animals are doing in their new homes. 

You can imagine my shock when I received a call two weeks ago from an upstate NY dog control that they had a dog with them that was microchipped to our rescue. This dog had not only come in as a stray, he had been driven to a local park after dark, pushed out of the car, screamed at to get away and then abandoned as he watched the car he came in drive away. Luckily a good samaritan witnessed this occur, and immediately brought the dog to animal control or else he likely would have frozen to death in the snow. My heart stopped when the ACO informed me that the dog’s name was Hercules. 

I quickly scrambled to find the adoption application from two years ago and gave the officer the phone number, address and name of the adopter. He and I both believed the dog must have been stolen, but regardless I told the ACO our adoption contract gives us the right to terminate the adoption at any time, and I wanted to reclaim ownership of the dog. Even though I was sure the adopter could never have done this, I still did not want one of our animals living in an area where he had been stolen. About an hour later, I received another call from the animal control officer. Not only had he been able to contact the adopter, the adopter had confirmed he was actually the one to dump Hercules in the park, and he offered no explanation or defense of his actions. I could not believe what I was hearing. We ALWAYS stand by our animals and will take back any animal that adopters need to return; there was no reason for this adopter to dump Hercules and nearly kill him in the cold. 

Above: Hercules, looking for a forever home once again.

Hercules is now back with our rescue, and other than some skin irritation caused by a poor diet, he is in pretty good shape. The man who abandoned him is being investigated and we are cooperating with authorities, hopeful that he will be charged and punished for what he has done. Our goal now is to find a new home for Herc where he will actually be cared for as deserved. The first few days after this unfortunate incident occurred I spent hours agonizing over what we needed to change, to do better. If I had done an in-person home visit would I still have approved the adopter? Did I check in enough post adoption? Should we change our adoption process or policies? 

I have concluded that our system, policies and process work, and that this unfortunate situation is just a consequence of our need to trust people at their word to care for our animals. We can and do run background checks, perform reference and home checks, require multiple visits (depending on the animal) and more, but at the end of the day we simply have to trust that our adopters will love and provide for their adopted pet. That will always be a terrifying thought for me as I have seen so much abuse and neglect working in rescue, and it is difficult to trust strangers. However, we cannot keep them all and the ones we adopt out allow us to bring in new animals who need our help. Our system only works because of our adopters and their ability to provide homes to animals in need. The man who adopted Hercules clearly did love and care for him at one point, and it seems that some emergency life event or mental breakdown may be the cause of his choice to abandon Hercules. We can think of no other explanation why someone who do this to a great dog they had owned for over two years, but we will never know for sure. We have to focus on the fact that we have great relationships with our other adopters, and the other animals we have adopted out have safe lives where there are loved. There are a few animals that still need us to help provide training, boarding or advice, but their owners love them and are committed to them for life. Many of these adopters, seeing Hercules’ story on social media, reached out to us to assure us we should never be concerned about the animal they adopted, that they truly are their forever home, and for that we will always be grateful.

Written by: Eleni Calomiris

Executive Director and one of the Founding Board Members of 

Wayward Ranch Animal Sanctuary

P.S. If you have adopted from Wayward Ranch and want to share new photos of your alumni enjoying life, check out the new Alumni group on our Facebook page: https://www.facebook.com/groups/2328537984100153/?ref=pages_groups_card&source_id=126222627840092

Below are some photos of our alumni we have recently received updates on:

[brajeshupadhyay]

How the coronavirus’ spike is complicating hopes of a full economic recovery

But on Friday, Heitzmann was cut loose again, hours before her shift was to begin.

“I don’t have any savings left,” the 28-year-old said. “I don’t know how long it’s going to be before I get a paycheck again.”

Millions of American workers are suffering from economic whiplash, thinking they were finally returning to work only to be sent home again because of the coronavirus’s latest surge. Stores, restaurants, gyms and other businesses that reopened weeks ago are shuttering once more, and this time Congress appears less inclined to provide additional aid. Other companies that had banked on customers returning and restrictions lifting — such as hotel chains, construction firms and movie theaters — are seeing hours cut and reopening dates pushed back indefinitely as consumer demand stalls.

And many governors, including some who had drawn scrutiny for initially playing down the virus’s risks, are issuing new safety restrictions, in some cases just weeks after the first round of guidelines had begun to lift. In recent weeks, three states — California, Florida and Texas — have implemented new policies that partly restrict restaurant or bar service. Nine others — Arkansas, Delaware, Idaho, Louisiana, Michigan, Nevada, New Jersey, New Mexico and North Carolina — have postponed or slowed reopening plans.

Thousands of workers are caught in these rapidly shifting seas, many of them hourly and low-wage service employees, and are now facing unemployment for a second time. They say the past few months have been jarring: navigating unemployment in March, preparing to go back to work in April or May, and now confronting the prospect of another long stretch without a paycheck.

This time, many say they’re on even shakier financial ground as they topple into yet another period without a job. They face what experts have begun calling a “fiscal cliff”: the July end date for the $600 in weekly supplemental aid that has helped keep so many families afloat.

“Luckily, I have rent for this month,” said Heitzmann, who pays $1,200 a month for a one-bedroom apartment. “But after that, I don’t know.”

For restaurants and bars, another big hit

For many restaurant and bar owners and workers, the past few weeks have brought an onslaught of bad news. Some said they watched wearily as infections began to tick up, just as they were starting to reopen after months of being closed.

Then came all the new cases.

Kell Duncan, who operates the Churchill, an indoor market in Phoenix with 10 shops and restaurants, described the bind restaurant owners have found themselves in with the caseload surging.

After cases crossed the 40,000 threshold in Arizona, he closed down the business and sent all 30 employees home for the second time — just a month after reopening — knowing that if he stayed open, someone would probably get sick.

“We’ve been lucky,” he said. “Ultimately, we said, ‘This just feels wrong. Let’s close and wait this thing out.’ “

Sherry Weir, who owns Big O’s Simply Delicious outside Fort Worth, made a similar choice, voluntarily shutting down her restaurant and deli on Friday.

The food service and bar industry — which employs more than 8 million people, or about 5 percent of the workforce before the pandemic — has been decimated by the virus, losing more than 6 million jobs in March and April. But a strong rebound of 1.4 million jobs in May helped drive down the country’s unemployment rate, sending hopes soaring that an economic recovery was underway. This new round of closures points to the significant challenges that will exist until a coronavirus treatment or vaccine is developed.

“It’s hard when there’s not been clear leadership and the population is getting mixed messages,” said Kevin Schulman, a professor of medicine and economics at Stanford University. “How do we plan for economic restoration while protecting public health? It is a little bit of Whack-a-Mole. There’s not a great model for that.”

Pain sinks deeper into the economy

The rising number of cases has sent a cascade of fear across other industries, too, not just those directly affected by shutdowns.

Samantha Hartman, 29, an administrative assistant at Rosen Hotels in Orlando, had been preparing to return to work at the end of July. The company had told employees that business would be back to normal by then, she said.

But a follow-up last week from her employer confirmed the sinking suspicions she felt as cases spiked in the area: The reopening would be pushed back to August.

Hartman, who has a heart condition and relies on her job not only for her income but for its generous health-care plan, fears that that date will prove similarly quixotic, she said.

She’s concerned about the end, scheduled for late July, of the extra $600 a week in federally funded unemployment benefits. And she said she feels torn between waiting out the potential return to her work and applying for jobs in other fields that may be less vulnerable to the shutdown than the hospitality industry is.

“I’m in a weird place where I have no idea where my life stands a month out,” she said. “That’s very terrifying.”

Kadeem Howell, a physical therapist in New York, has spent the past week teaching himself how to trade stocks and options after being furloughed for the second time in three months.

When he was laid off in March, Howell relied on unemployment benefits to pay his bills. But he was called back to work in May at a Manhattan orthopedic clinic, a mixed blessing as he worried about bringing the virus back to his home in Westchester County, where he and his wife live with her parents, who are in their 70s.

His bosses gave him an ultimatum: He could show up for work or voluntarily terminate his position, which would’ve meant forfeiting unemployment insurance.

“I just kept thinking: Do I risk going on public transportation, going into the city, knowing I’m going into the epicenter of this disease?” he said. “It’s a very uncertain and frustrating time, but I didn’t feel like I had much of a choice. I decided to keep working.”

But he was furloughed again on June 15. He and his wife had hoped to buy a house this year but are putting their plans on hold.

“I feel stuck,” he said. “Do I stay on unemployment? Do I apply for a job somewhere else? Do I just wait and sit on my heels? There is no easy answer.”

No end in sight

The fresh round of closures is raising fears that the already challenged recovery could stall out.

The number of people who are continuously receiving unemployment insurance ticked down slightly last week, from 20.5 million to 19.5 million.

But there are those, such as Michael Hebert, 25, whose financial challenges aren’t captured in the weekly statistics.

Hebert is technically employed, but just barely: The 52 hours a week he used to work at a hot-dog eatery at the airport and the Harrah’s casino in New Orleans before the crisis have been cut down to eight, after he was summoned back to work a few weeks ago.

Hebert said he gets no sick time, vacation pay or health benefits from his work, just $10 an hour, which hardly pays the bills.

“It’s barely enough to pay a phone bill,” he said. “Two seconds, it’s gone. It’s a struggle because if we don’t meet the bills, we’re going to be on the streets.”

Scholars have begun debating how influential temporary shutdowns are on the country’s employment levels.

According to a preliminary study by two Harvard researchers, limitations at restaurants, bars and nonessential businesses accounted for 4.4 to 8.5 percent of the significant increase in unemployment in mid-March.

Public health experts said the threat of a new wave of closures is why stringent measures have been needed to prevent the virus’s spread.

“It’s an impossible choice,” said Emily Timm, a senior director at the Texas-based Workers Defense Project, a nonprofit organization that helps immigrant and undocumented workers. “People don’t want to risk their family’s health. But it’s not a choice if you don’t have access to the safety net or you were living paycheck to paycheck before the coronavirus hit.”

The organization has been issuing $750 grants to laid-off workers who weren’t eligible for unemployment insurance because of their documentation status. Timm said many of the recent beneficiaries are people who had gone back to work in the restaurant or hospitality industries only to be laid off again.

Hartman, the Orlando-based administrative assistant for Rosen Hotels, said she thinks elected officials in states with rising cases who minimized the threat of the virus are responsible for the increase — and the ensuing damage to the economy.

“The longer we stay open, the more our cases rise, the more it gets publicized in the news and the more it puts off people from coming here,” Hartman said. “So I think we should have stayed shut longer — that initial shutdown was less detrimental than shutting down a second time.”

There are some indications that factors beyond the shutdowns weigh more heavily on the economy.

The Federal Reserve Bank of St. Louis issued a recent report saying that businesses said declining demand from consumers was the top constraint on their recovery, ahead of social distancing requirements and concerns about their workers’ health.

“The pace of business reopening has to be completely in sync with the amount that demand is going up,” one of the authors, Charles S. Gascon, an economist at the bank, said in an interview. “It’s not like there’s an on or off switch in the economy that you flip and things go back to normal. Things have to get back up to whatever the new normal is.”

Only four states — New Hampshire, New Jersey, North Dakota and Vermont, representing just 4 percent of the U.S. population — are meeting all the federal criteria for reopening, according to a recent report from Goldman Sachs.

Back in Phoenix, Duncan says it could be months before he opens the Churchill again.

He and his team spent weeks rethinking layouts, adding foot pedals to doors and installing hand sanitizer stations after the business closed the first time, in mid-March. They kept paying employees — first from their own pockets and then with money from a $200,000 Paycheck Protection Program loan.

But Duncan said he still had a nagging feeling that he wasn’t doing enough to protect workers and customers, as the number of coronavirus cases around him ballooned. There was little guidance from local officials, and he couldn’t get clear answers from his insurance company about what would happen if there were an outbreak at the Churchill.

He has deferred his monthly mortgage payments, but he says the uncertainty of when — or how — to reopen has been debilitating.

Weir and her husband, who own the deli outside Fort Worth, told their staff that they’re closing for two weeks. But they have a plan, should they need to remain dark through the end of the year: using money from a small loan they took out to expand their business during more auspicious times to keep it and its eight employees afloat now.

But there are more important considerations than the health of the business at the moment.

“It was just a matter of time before we got sick, or somebody else did because they were in our establishment,” Weir said. “I don’t want any part in that.”

The post How the coronavirus’ spike is complicating hopes of a full economic recovery appeared first on Sansaar Times.

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Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ http://www.nature-business.com/nature-chinas-health-care-crisis-lines-before-dawn-violence-and-no-trust/

Nature

Video

Homemade cancer drugs, violence in hospitals, doctor shortages: We take you inside China’s broken health care system to reveal how dire the situation is for over a billion people.Published OnSept. 30, 2018CreditCreditImage by Gilles Sabrié for The New York Times

BEIJING — Well before dawn, nearly a hundred people stood in line outside one of the capital’s top hospitals.

They were hoping to get an appointment with a specialist, a chance for access to the best health care in the country. Scalpers hawked medical visits for a fee, ignoring repeated crackdowns by the government.

A Beijing resident in line was trying to get his father in to see a neurologist. A senior lawmaker from Liaoning, a northeastern province, needed a second opinion on her daughter’s blood disorder.

Mao Ning, who was helping her friend get an appointment with a dermatologist, arrived at 4 a.m. She was in the middle of the line.

“There’s no choice — everyone comes to Beijing,” Ms. Mao, 40, said. “I think this is an unscientific approach and is not in keeping with our national conditions. We shouldn’t have people do this, right? There should be a reasonable system.”

The long lines, a standard feature of hospital visits in China, are a symptom of a health care system in crisis.

Image

Dr. Ye Minghao, a family practitioner in Shanghai, sees up to 80 patients a day. He enjoys his work, he said, but is unhappy about the lack of respect for his field.CreditGilles Sabrié for The New York Times

An economic boom over the past three decades has transformed China from a poor farming nation to the world’s second-largest economy. The cradle-to-grave system of socialized medicine has improved life expectancy and lowered maternal mortality rates.

But the system cannot adequately support China’s population of more than one billion people. The major gaps and inequalities threaten to undermine China’s progress, social stability and financial health — creating a serious challenge for President Xi Jinping and the Communist Party.

Then, there are the scandals. In July, hundreds of thousands of children were found to have been injected with faulty vaccines. The news angered the public, rattling confidence in the government and amplifying frustration with the health care system.

While the wealthy have access to the best care in top hospitals with foreign doctors, most people are relegated to overcrowded hospitals. In the countryside, people must rely on village clinics, or travel hundreds of miles to find the closest facility.

The country does not have a functioning primary care system, the first line of defense for illness and injury. China has one general practitioner for every 6,666 people, compared with the international standard of one for every 1,500 to 2,000 people, according to the World Health Organization.

Instead of going to a doctor’s office or a community clinic, people rush to the hospitals to see specialists, even for fevers and headaches. This winter, flu-stricken patients camped out overnight with blankets in the corridors of several Beijing hospitals, according to state media.

Hospitals are understaffed and overwhelmed. Specialists are overworked, seeing as many as 200 patients a day.

Image

Nurses reviewing the patient list at the Gaoqiao community health service center in Shanghai. Hoping to get more people to use local clinics instead of hospitals, the government is paying specialists subsidies to staff them.CreditGilles Sabrié for The New York Times

And people are frustrated, with some resorting to violence. In China, attacks on doctors are so common that they have a name: “yi nao,” or “medical disturbance.”

In 2016, Mr. Xi unveiled the country’s first long-term blueprint to improve health care since the nation’s founding in 1949. Called Healthy China 2030, it pledged to bolster health innovation and make access to medical care more equal.

The deficiency in doctors has taken on more urgency as the Chinese government grapples with the mounting health problems of its vast population. Heart disease, strokes, diabetes and chronic lung disease account for 80 percent of deaths in China, according to a World Bank report in 2011.

Mao Qun’an, the spokesman for the National Health and Family Planning Commission, acknowledged that the hospitals could no longer meet the public’s needs.

“If you don’t get the grass roots right, then the medical problems in China cannot be solved,” Mr. Mao said. “So what we’re doing now is trying to return to the normal state.”

A Lack of Respect

On some mornings, Dr. Huang Dazhi, a general practitioner in Shanghai, rides his motorbike to a nursing home, where he treats about 40 patients a week. During lunchtime, he sprints back to his clinic to stock up on their medication and then heads back to the nursing home.

Afterward, he makes house calls to three or four people. On other days, he goes to his clinic, where he sees about 70 patients. At night, he doles out advice about high-blood-pressure medications and colds to his patients, who call him on his mobile phone.

Image

Dr. Huang Dazhi, a general practitioner in Shanghai, is paid about $1,340 a month — roughly his starting pay as a specialist 12 years ago.CreditGilles Sabrié for The New York Times

For all this, Dr. Huang is paid about $1,340 a month — roughly the same he was making starting out as a specialist in internal medicine 12 years ago.

“The social status of a general practitioner is not high enough,” Dr. Huang said, wearing a gray Nike T-shirt and jeans under his doctor’s coat. “It feels like there’s still a large gap when you compare us to specialists.”

In a country where pay is equated with respect, the public views family doctors as having a lower status and weaker credentials than specialists. Among nearly 18,000 doctors, only one-third thought that they were respected by the public, according to a 2017 survey by the Chinese Academy of Medical Sciences, Peking Union Medical College, Brigham and Women’s Hospital in Boston, Harvard Medical School, the Harvard T.H. Chan School of Public Health and the U.S. China Health Summit.

“There is no trust in the primary care system among the population because the good doctors don’t go there,” said Bernhard Schwartländer, a senior aide at the World Health Organization and its former representative to China. “They cannot make money.”

China once had a broad, if somewhat basic, primary health care system. “Barefoot doctors” roamed the countryside treating minor ailments. In the cities, people got their health care at clinics run by state-owned companies.

China’s “barefoot doctor” system was one of the Communist revolution’s most notable successes. In 1965, Chairman Mao, troubled by the lack of health care in the countryside, envisioned an army of people who spent half their time farming (many worked in the fields without shoes) and half their time treating patients. They weren’t doctors, but rather a sort of health care SWAT team. The authorities gave them a short training period — several months to a year — and a bag of limited medicine and equipment.

Average life expectancy in China increased to 63 years in 1970 from 44 in 1960, according to Theodore H. Tulchinsky and Elena A. Varavikova, authors of “The New Public Health,” a book about global medical care. The maternal mortality rate in rural China fell to 41.3 per 100,000 people from 150 per 100,000 before 1949, according to a 2008 article published by the World Health Organization. In the same period, the infant mortality rate fell to 18.6 per 1,000 from 200.

Image

A training session for family doctors at the Weifang community health service center in Shanghai.CreditGilles Sabrié for The New York Times

But the public was fed up that it could not get medical treatment whenever or wherever it wanted. People needed a referral to see a specialist in a hospital.

In the mid-1980s, the government lifted the barriers, allowing people to be treated in hospitals. At the same time, China began an economic overhaul that led to the dismantling of the entire system. Government subsidies were cut drastically, and hospitals had to come up with ways to generate profits.

As hospitals started investing in high-tech machines and expanded to meet their new financial needs, medical students were drawn to them. Many believed that being a specialist would guarantee them an “iron rice bowl,” a job that was secure with an extensive safety net that included housing and a pension.

Dr. Huang initially followed the more lucrative path. After graduating from medical school in 2006, he started working as an internist in a hospital in Shanghai.

But he kept seeing patients with simple aftercare needs like removing stitches, changing catheters and switching medication. “These things really should not be done by us specialists,” he said.

When Dr. Huang saw a newspaper article about general practitioners, he decided to enroll in a training program in 2007. He was inspired by his aunt, a “barefoot doctor” in Mingguang, a city in Anhui Province, one of the poorest regions in China.

As a boy, he had followed his aunt as she went to people’s homes to deliver babies and give injections. “After becoming a doctor, I’ve realized that the people’s needs for ‘barefoot doctors’ is still very much in demand,” he said.

Image

An electronic board at the entrance of Peking Union Hospital displays the number of doctors available and their specialty.CreditGilles Sabrié for The New York Times

Corruption and Backlash

In March, a doctor was killed by his patient’s husband. In November 2016, a man attacked a doctor after an argument over his daughter’s treatment. The month before, a father stabbed a pediatrician 15 times after his daughter died shortly after her birth. The doctor did not survive.

Dr. Zhao Lizhong, an emergency room doctor in Beijing, was sitting at a computer and writing a patient’s diagnosis when Lu Fu’ke plunged a knife into his neck in April 2012. Around him, patients screamed.

Hours earlier, Mr. Lu had stabbed Dr. Xing Zhimin, who had treated him for rhinitis, in the Peking University People’s Hospital and fled. Police officers arrested him in his hometown, Zhuozhou in the northern province of Hebei, later that month. Mr. Lu was sentenced to 13 years in jail.

“We know that this kind of thing can happen at any time,” Dr. Zhao said.

The root of the violence is all the same: a mistrust of the medical system.

It goes back to the market reforms under Deng Xiaoping in the 1980s. After the government cut back subsidies to hospitals, doctors were forced to find ways to make money. Many accepted kickbacks from drug companies and gifts from patients.

In a survey of more than 570 residents in Beijing, Shanghai and Guangzhou conducted in 2013 by Cheris Chan, a sociology professor at the University of Hong Kong, more than half said they and members of their family gave “red envelopes” as cash gifts to doctors for surgery during 2000-12.

Dr. Yu Ying, who worked as an emergency room doctor at Peking Union Hospital, one of China’s top hospitals, said she was once a valiant defender of her profession. On her widely followed account on Weibo, China’s version of Twitter, she pushed back against critics who called doctors “white-eyed wolves.”

Image

Dr. Yu Ying, who worked in Peking Union Hospital’s emergency room, said she had heard accounts of doctors who accepted thousands of dollars in kickbacks.CreditGilles Sabrié for The New York Times

“After I discovered the truth, I really had to give myself a slap in the face,” she said.

Dr. Yu said she had heard accounts from outpatient doctors who accepted thousands of dollars in kickbacks from drug companies — “cash that was bundled into plastic bags.”

“In the entire system, the majority of doctors accept red envelopes and kickbacks,” she said.

The corruption is endemic. GlaxoSmithKline paid a $500 million fine in 2014, the highest ever in China at the time, for giving kickbacks to doctors and hospitals that prescribed its medicines. Eli Lilly, Pfizer and other global drug giants have settled with regulators over similar behavior.

It all makes for a violent mix.

Many hospitals are taking measures to protect their workers. In the southern city of Guangzhou, the Zhongshan Hospital has hired taekwondo experts to teach doctors self-defense techniques. Hospitals in the eastern city of Jinan are paying private security companies for protection. Last year, the government pledged to station an adequate number of police officers in emergency departments, where most doctor-patient violence occurs.

Mr. Mao, the spokesman for the health ministry, said that while the figures for attacks on medical personnel looked alarming, they needed to be put in context. Chinese patients sought medical help eight billion times in 2016, a number that is equivalent to the world’s population, according to Mr. Mao. There were roughly 50,000 medical-related disputes in that period, a tiny fraction of the total number of health visits.

“Therefore, our judgment is the doctor-patient relationship in reality isn’t tense,” Mr. Mao said.

On the Front Line

If Beijing hopes to overhaul health care, it needs to persuade a skeptical public to stop going to the hospital for the sniffles.

To help change the culture, China is pushing each household to sign a contract with a family doctor by 2020 and subsidizing patients’ visits. General practitioners will also have the authority to make appointments directly with top specialists, rather than leaving patients to make their own at hospitals.

Such measures would make it easier for patients to transfer to top hospitals without a wait, while potentially giving them more personalized care from a doctor who knows their history. It could also cut down on costs, since it is cheaper under government insurance to see a family doctor.

Image

Dr. Zhu Min, who practices family medicine in Shanghai, splits her time between the local clinic, a hospital and patients’ homes.CreditGilles Sabrié for The New York Times

After the government’s directive, Dr. Yang Lan has signed up more than 200 patients, and monitors their health for about $1,220 a month. From her office in the Xinhua community health center, a run-down place with elderly patients milling about in the corridors, she keeps track of her patients with an Excel sheet on her computer. She said she had memorized their medical history and addresses.

Dr. Yang, 31, said her practice was largely free of grumpy patients and, as a result, “yi nao.” She sees 50 to 60 patients in a workday of about seven and a half hours. In the United States, a family doctor has 83 “patient encounters” in a 45-hour workweek, according to a 2017 survey by the American Academy of Family Physicians. That’s about 16 patients in a nine-hour workday.

The patients get something, too — a doctor who has time for them. Every three months, Dr. Yang has a face-to-face meeting with her patients, either during a house call or at her clinic. She’s available to dispense round-the-clock advice to her patients on WeChat, a popular messaging app in China. A patient is generally kept in the waiting room for a brief period and, if necessary, gets to talk with her for at least 15 minutes.

On a hot summer day, an elderly woman with white hair walked into Dr. Yang’s clinic. She has cardiovascular disease, and Dr. Yang told her to watch what she ate. Next, a man with diabetes dropped in. “Hey, you got a haircut!” Dr. Yang exclaimed. At one point, four retirees swarmed Dr. Yang’s room, talking over one another.

“I think she’s really warm and considerate,” said Cai Zhenghua, the patient with diabetes. He used to seek treatment at a hospital, he said, adding, “The time spent interacting with doctors here is much longer.”

The government aims to increase the number of general practitioners to two or three, and eventually five, for every 10,000 people, from 1.5 now. But to even have a chance of reaching its goals, China needs to train thousands of doctors who have no inkling of how a primary care system should function and little interest in leaving their cushy jobs in the public hospitals.

It is forcing hospital specialists to staff the community clinics every week and paying those doctors subsidies to do so. It is also trying to improve the bedside manner of doctors with government-backed training programs.

Image

Patients waiting for lab results at the Weifang clinic.CreditGilles Sabrié for The New York Times

In Shanghai, Du Zhaohui, then the head of the Weifang community health service center, introduced a test that uses mock patients to evaluate the care and skills of general practitioners. The doctors have 15 minutes to examine “patients.” The teachers use a checklist to grade the doctors on things like making “appropriate eye contact” and “responding appropriately to a patient’s emotions.”

At a recent test, one doctor, wearing crystal-studded Birkenstock sandals, examined a patient who had insufficient blood flow to the brain by swinging a tiny silver hammer, the equipment that is used for testing reflexes.

“That isn’t the right way,” Li Yaling, head of the center’s science and education department, said with a sigh. She said the doctor was probably too nervous and should have used a cotton swab to stroke the soles of the patient’s feet instead.

Dr. Zhu Shanzhu, a teacher in the program, said one of the main problems was that doctors did too few physical examinations in the community clinics. Many of them lean toward prescribing medicine instead. Clinical reasoning, too, is poor, she said.

In 2000, Dr. Zhu designed a course to train general practitioners in Shanghai’s Zhongshan Hospital, at the request of its director. Her first course was free. No one showed up.

Nearly two decades later, Dr. Zhu, 71, says that training is still insufficient and doctors do not spend enough time studying the latest research and techniques in their field.

“If there’s more money, the good people will come,” she said. “And a high economic status will elevate the social status.”

The government has pledged to increase the salaries of family doctors. But Dr. Zhu isn’t optimistic.

“All these ministries need to coordinate among themselves,” she said. “Our country’s affairs, you know, they aren’t easy.”

Follow Sui-Lee Wee on Twitter: @suilee.

Research was contributed by Zhang Tiantian, Zoe Mou, Qi Xu, Tang Yucheng, Amy Cheng and Elsie Chen.

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Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ http://www.nature-business.com/nature-chinas-health-care-crisis-lines-before-dawn-violence-and-no-trust/

Nature

Video

Homemade cancer drugs, violence in hospitals, doctor shortages: We take you inside China’s broken health care system to reveal how dire the situation is for over a billion people.Published OnSept. 30, 2018CreditCreditImage by Gilles Sabrié for The New York Times

BEIJING — Well before dawn, nearly a hundred people stood in line outside one of the capital’s top hospitals.

They were hoping to get an appointment with a specialist, a chance for access to the best health care in the country. Scalpers hawked medical visits for a fee, ignoring repeated crackdowns by the government.

A Beijing resident in line was trying to get his father in to see a neurologist. A senior lawmaker from Liaoning, a northeastern province, needed a second opinion on her daughter’s blood disorder.

Mao Ning, who was helping her friend get an appointment with a dermatologist, arrived at 4 a.m. She was in the middle of the line.

“There’s no choice — everyone comes to Beijing,” Ms. Mao, 40, said. “I think this is an unscientific approach and is not in keeping with our national conditions. We shouldn’t have people do this, right? There should be a reasonable system.”

The long lines, a standard feature of hospital visits in China, are a symptom of a health care system in crisis.

Image

Dr. Ye Minghao, a family practitioner in Shanghai, sees up to 80 patients a day. He enjoys his work, he said, but is unhappy about the lack of respect for his field.CreditGilles Sabrié for The New York Times

An economic boom over the past three decades has transformed China from a poor farming nation to the world’s second-largest economy. The cradle-to-grave system of socialized medicine has improved life expectancy and lowered maternal mortality rates.

But the system cannot adequately support China’s population of more than one billion people. The major gaps and inequalities threaten to undermine China’s progress, social stability and financial health — creating a serious challenge for President Xi Jinping and the Communist Party.

Then, there are the scandals. In July, hundreds of thousands of children were found to have been injected with faulty vaccines. The news angered the public, rattling confidence in the government and amplifying frustration with the health care system.

While the wealthy have access to the best care in top hospitals with foreign doctors, most people are relegated to overcrowded hospitals. In the countryside, people must rely on village clinics, or travel hundreds of miles to find the closest facility.

The country does not have a functioning primary care system, the first line of defense for illness and injury. China has one general practitioner for every 6,666 people, compared with the international standard of one for every 1,500 to 2,000 people, according to the World Health Organization.

Instead of going to a doctor’s office or a community clinic, people rush to the hospitals to see specialists, even for fevers and headaches. This winter, flu-stricken patients camped out overnight with blankets in the corridors of several Beijing hospitals, according to state media.

Hospitals are understaffed and overwhelmed. Specialists are overworked, seeing as many as 200 patients a day.

Image

Nurses reviewing the patient list at the Gaoqiao community health service center in Shanghai. Hoping to get more people to use local clinics instead of hospitals, the government is paying specialists subsidies to staff them.CreditGilles Sabrié for The New York Times

And people are frustrated, with some resorting to violence. In China, attacks on doctors are so common that they have a name: “yi nao,” or “medical disturbance.”

In 2016, Mr. Xi unveiled the country’s first long-term blueprint to improve health care since the nation’s founding in 1949. Called Healthy China 2030, it pledged to bolster health innovation and make access to medical care more equal.

The deficiency in doctors has taken on more urgency as the Chinese government grapples with the mounting health problems of its vast population. Heart disease, strokes, diabetes and chronic lung disease account for 80 percent of deaths in China, according to a World Bank report in 2011.

Mao Qun’an, the spokesman for the National Health and Family Planning Commission, acknowledged that the hospitals could no longer meet the public’s needs.

“If you don’t get the grass roots right, then the medical problems in China cannot be solved,” Mr. Mao said. “So what we’re doing now is trying to return to the normal state.”

A Lack of Respect

On some mornings, Dr. Huang Dazhi, a general practitioner in Shanghai, rides his motorbike to a nursing home, where he treats about 40 patients a week. During lunchtime, he sprints back to his clinic to stock up on their medication and then heads back to the nursing home.

Afterward, he makes house calls to three or four people. On other days, he goes to his clinic, where he sees about 70 patients. At night, he doles out advice about high-blood-pressure medications and colds to his patients, who call him on his mobile phone.

Image

Dr. Huang Dazhi, a general practitioner in Shanghai, is paid about $1,340 a month — roughly his starting pay as a specialist 12 years ago.CreditGilles Sabrié for The New York Times

For all this, Dr. Huang is paid about $1,340 a month — roughly the same he was making starting out as a specialist in internal medicine 12 years ago.

“The social status of a general practitioner is not high enough,” Dr. Huang said, wearing a gray Nike T-shirt and jeans under his doctor’s coat. “It feels like there’s still a large gap when you compare us to specialists.”

In a country where pay is equated with respect, the public views family doctors as having a lower status and weaker credentials than specialists. Among nearly 18,000 doctors, only one-third thought that they were respected by the public, according to a 2017 survey by the Chinese Academy of Medical Sciences, Peking Union Medical College, Brigham and Women’s Hospital in Boston, Harvard Medical School, the Harvard T.H. Chan School of Public Health and the U.S. China Health Summit.

“There is no trust in the primary care system among the population because the good doctors don’t go there,” said Bernhard Schwartländer, a senior aide at the World Health Organization and its former representative to China. “They cannot make money.”

China once had a broad, if somewhat basic, primary health care system. “Barefoot doctors” roamed the countryside treating minor ailments. In the cities, people got their health care at clinics run by state-owned companies.

China’s “barefoot doctor” system was one of the Communist revolution’s most notable successes. In 1965, Chairman Mao, troubled by the lack of health care in the countryside, envisioned an army of people who spent half their time farming (many worked in the fields without shoes) and half their time treating patients. They weren’t doctors, but rather a sort of health care SWAT team. The authorities gave them a short training period — several months to a year — and a bag of limited medicine and equipment.

Average life expectancy in China increased to 63 years in 1970 from 44 in 1960, according to Theodore H. Tulchinsky and Elena A. Varavikova, authors of “The New Public Health,” a book about global medical care. The maternal mortality rate in rural China fell to 41.3 per 100,000 people from 150 per 100,000 before 1949, according to a 2008 article published by the World Health Organization. In the same period, the infant mortality rate fell to 18.6 per 1,000 from 200.

Image

A training session for family doctors at the Weifang community health service center in Shanghai.CreditGilles Sabrié for The New York Times

But the public was fed up that it could not get medical treatment whenever or wherever it wanted. People needed a referral to see a specialist in a hospital.

In the mid-1980s, the government lifted the barriers, allowing people to be treated in hospitals. At the same time, China began an economic overhaul that led to the dismantling of the entire system. Government subsidies were cut drastically, and hospitals had to come up with ways to generate profits.

As hospitals started investing in high-tech machines and expanded to meet their new financial needs, medical students were drawn to them. Many believed that being a specialist would guarantee them an “iron rice bowl,” a job that was secure with an extensive safety net that included housing and a pension.

Dr. Huang initially followed the more lucrative path. After graduating from medical school in 2006, he started working as an internist in a hospital in Shanghai.

But he kept seeing patients with simple aftercare needs like removing stitches, changing catheters and switching medication. “These things really should not be done by us specialists,” he said.

When Dr. Huang saw a newspaper article about general practitioners, he decided to enroll in a training program in 2007. He was inspired by his aunt, a “barefoot doctor” in Mingguang, a city in Anhui Province, one of the poorest regions in China.

As a boy, he had followed his aunt as she went to people’s homes to deliver babies and give injections. “After becoming a doctor, I’ve realized that the people’s needs for ‘barefoot doctors’ is still very much in demand,” he said.

Image

An electronic board at the entrance of Peking Union Hospital displays the number of doctors available and their specialty.CreditGilles Sabrié for The New York Times

Corruption and Backlash

In March, a doctor was killed by his patient’s husband. In November 2016, a man attacked a doctor after an argument over his daughter’s treatment. The month before, a father stabbed a pediatrician 15 times after his daughter died shortly after her birth. The doctor did not survive.

Dr. Zhao Lizhong, an emergency room doctor in Beijing, was sitting at a computer and writing a patient’s diagnosis when Lu Fu’ke plunged a knife into his neck in April 2012. Around him, patients screamed.

Hours earlier, Mr. Lu had stabbed Dr. Xing Zhimin, who had treated him for rhinitis, in the Peking University People’s Hospital and fled. Police officers arrested him in his hometown, Zhuozhou in the northern province of Hebei, later that month. Mr. Lu was sentenced to 13 years in jail.

“We know that this kind of thing can happen at any time,” Dr. Zhao said.

The root of the violence is all the same: a mistrust of the medical system.

It goes back to the market reforms under Deng Xiaoping in the 1980s. After the government cut back subsidies to hospitals, doctors were forced to find ways to make money. Many accepted kickbacks from drug companies and gifts from patients.

In a survey of more than 570 residents in Beijing, Shanghai and Guangzhou conducted in 2013 by Cheris Chan, a sociology professor at the University of Hong Kong, more than half said they and members of their family gave “red envelopes” as cash gifts to doctors for surgery during 2000-12.

Dr. Yu Ying, who worked as an emergency room doctor at Peking Union Hospital, one of China’s top hospitals, said she was once a valiant defender of her profession. On her widely followed account on Weibo, China’s version of Twitter, she pushed back against critics who called doctors “white-eyed wolves.”

Image

Dr. Yu Ying, who worked in Peking Union Hospital’s emergency room, said she had heard accounts of doctors who accepted thousands of dollars in kickbacks.CreditGilles Sabrié for The New York Times

“After I discovered the truth, I really had to give myself a slap in the face,” she said.

Dr. Yu said she had heard accounts from outpatient doctors who accepted thousands of dollars in kickbacks from drug companies — “cash that was bundled into plastic bags.”

“In the entire system, the majority of doctors accept red envelopes and kickbacks,” she said.

The corruption is endemic. GlaxoSmithKline paid a $500 million fine in 2014, the highest ever in China at the time, for giving kickbacks to doctors and hospitals that prescribed its medicines. Eli Lilly, Pfizer and other global drug giants have settled with regulators over similar behavior.

It all makes for a violent mix.

Many hospitals are taking measures to protect their workers. In the southern city of Guangzhou, the Zhongshan Hospital has hired taekwondo experts to teach doctors self-defense techniques. Hospitals in the eastern city of Jinan are paying private security companies for protection. Last year, the government pledged to station an adequate number of police officers in emergency departments, where most doctor-patient violence occurs.

Mr. Mao, the spokesman for the health ministry, said that while the figures for attacks on medical personnel looked alarming, they needed to be put in context. Chinese patients sought medical help eight billion times in 2016, a number that is equivalent to the world’s population, according to Mr. Mao. There were roughly 50,000 medical-related disputes in that period, a tiny fraction of the total number of health visits.

“Therefore, our judgment is the doctor-patient relationship in reality isn’t tense,” Mr. Mao said.

On the Front Line

If Beijing hopes to overhaul health care, it needs to persuade a skeptical public to stop going to the hospital for the sniffles.

To help change the culture, China is pushing each household to sign a contract with a family doctor by 2020 and subsidizing patients’ visits. General practitioners will also have the authority to make appointments directly with top specialists, rather than leaving patients to make their own at hospitals.

Such measures would make it easier for patients to transfer to top hospitals without a wait, while potentially giving them more personalized care from a doctor who knows their history. It could also cut down on costs, since it is cheaper under government insurance to see a family doctor.

Image

Dr. Zhu Min, who practices family medicine in Shanghai, splits her time between the local clinic, a hospital and patients’ homes.CreditGilles Sabrié for The New York Times

After the government’s directive, Dr. Yang Lan has signed up more than 200 patients, and monitors their health for about $1,220 a month. From her office in the Xinhua community health center, a run-down place with elderly patients milling about in the corridors, she keeps track of her patients with an Excel sheet on her computer. She said she had memorized their medical history and addresses.

Dr. Yang, 31, said her practice was largely free of grumpy patients and, as a result, “yi nao.” She sees 50 to 60 patients in a workday of about seven and a half hours. In the United States, a family doctor has 83 “patient encounters” in a 45-hour workweek, according to a 2017 survey by the American Academy of Family Physicians. That’s about 16 patients in a nine-hour workday.

The patients get something, too — a doctor who has time for them. Every three months, Dr. Yang has a face-to-face meeting with her patients, either during a house call or at her clinic. She’s available to dispense round-the-clock advice to her patients on WeChat, a popular messaging app in China. A patient is generally kept in the waiting room for a brief period and, if necessary, gets to talk with her for at least 15 minutes.

On a hot summer day, an elderly woman with white hair walked into Dr. Yang’s clinic. She has cardiovascular disease, and Dr. Yang told her to watch what she ate. Next, a man with diabetes dropped in. “Hey, you got a haircut!” Dr. Yang exclaimed. At one point, four retirees swarmed Dr. Yang’s room, talking over one another.

“I think she’s really warm and considerate,” said Cai Zhenghua, the patient with diabetes. He used to seek treatment at a hospital, he said, adding, “The time spent interacting with doctors here is much longer.”

The government aims to increase the number of general practitioners to two or three, and eventually five, for every 10,000 people, from 1.5 now. But to even have a chance of reaching its goals, China needs to train thousands of doctors who have no inkling of how a primary care system should function and little interest in leaving their cushy jobs in the public hospitals.

It is forcing hospital specialists to staff the community clinics every week and paying those doctors subsidies to do so. It is also trying to improve the bedside manner of doctors with government-backed training programs.

Image

Patients waiting for lab results at the Weifang clinic.CreditGilles Sabrié for The New York Times

In Shanghai, Du Zhaohui, then the head of the Weifang community health service center, introduced a test that uses mock patients to evaluate the care and skills of general practitioners. The doctors have 15 minutes to examine “patients.” The teachers use a checklist to grade the doctors on things like making “appropriate eye contact” and “responding appropriately to a patient’s emotions.”

At a recent test, one doctor, wearing crystal-studded Birkenstock sandals, examined a patient who had insufficient blood flow to the brain by swinging a tiny silver hammer, the equipment that is used for testing reflexes.

“That isn’t the right way,” Li Yaling, head of the center’s science and education department, said with a sigh. She said the doctor was probably too nervous and should have used a cotton swab to stroke the soles of the patient’s feet instead.

Dr. Zhu Shanzhu, a teacher in the program, said one of the main problems was that doctors did too few physical examinations in the community clinics. Many of them lean toward prescribing medicine instead. Clinical reasoning, too, is poor, she said.

In 2000, Dr. Zhu designed a course to train general practitioners in Shanghai’s Zhongshan Hospital, at the request of its director. Her first course was free. No one showed up.

Nearly two decades later, Dr. Zhu, 71, says that training is still insufficient and doctors do not spend enough time studying the latest research and techniques in their field.

“If there’s more money, the good people will come,” she said. “And a high economic status will elevate the social status.”

The government has pledged to increase the salaries of family doctors. But Dr. Zhu isn’t optimistic.

“All these ministries need to coordinate among themselves,” she said. “Our country’s affairs, you know, they aren’t easy.”

Follow Sui-Lee Wee on Twitter: @suilee.

Research was contributed by Zhang Tiantian, Zoe Mou, Qi Xu, Tang Yucheng, Amy Cheng and Elsie Chen.

A version of this article appears in print on

, on Page

A

1

of the New York edition

with the headline:

Lines, Bribes and Violence: A Health Care Crisis

. Order Reprints | Today’s Paper | Subscribe

Read More | https://www.nytimes.com/2018/09/30/business/china-health-care-doctors.html |

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’, in 2018-10-01 14:49:05

[blogparadiseisland]

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ http://www.nature-business.com/nature-chinas-health-care-crisis-lines-before-dawn-violence-and-no-trust/

Nature

Video

Homemade cancer drugs, violence in hospitals, doctor shortages: We take you inside China’s broken health care system to reveal how dire the situation is for over a billion people.Published OnSept. 30, 2018CreditCreditImage by Gilles Sabrié for The New York Times

BEIJING — Well before dawn, nearly a hundred people stood in line outside one of the capital’s top hospitals.

They were hoping to get an appointment with a specialist, a chance for access to the best health care in the country. Scalpers hawked medical visits for a fee, ignoring repeated crackdowns by the government.

A Beijing resident in line was trying to get his father in to see a neurologist. A senior lawmaker from Liaoning, a northeastern province, needed a second opinion on her daughter’s blood disorder.

Mao Ning, who was helping her friend get an appointment with a dermatologist, arrived at 4 a.m. She was in the middle of the line.

“There’s no choice — everyone comes to Beijing,” Ms. Mao, 40, said. “I think this is an unscientific approach and is not in keeping with our national conditions. We shouldn’t have people do this, right? There should be a reasonable system.”

The long lines, a standard feature of hospital visits in China, are a symptom of a health care system in crisis.

Image

Dr. Ye Minghao, a family practitioner in Shanghai, sees up to 80 patients a day. He enjoys his work, he said, but is unhappy about the lack of respect for his field.CreditGilles Sabrié for The New York Times

An economic boom over the past three decades has transformed China from a poor farming nation to the world’s second-largest economy. The cradle-to-grave system of socialized medicine has improved life expectancy and lowered maternal mortality rates.

But the system cannot adequately support China’s population of more than one billion people. The major gaps and inequalities threaten to undermine China’s progress, social stability and financial health — creating a serious challenge for President Xi Jinping and the Communist Party.

Then, there are the scandals. In July, hundreds of thousands of children were found to have been injected with faulty vaccines. The news angered the public, rattling confidence in the government and amplifying frustration with the health care system.

While the wealthy have access to the best care in top hospitals with foreign doctors, most people are relegated to overcrowded hospitals. In the countryside, people must rely on village clinics, or travel hundreds of miles to find the closest facility.

The country does not have a functioning primary care system, the first line of defense for illness and injury. China has one general practitioner for every 6,666 people, compared with the international standard of one for every 1,500 to 2,000 people, according to the World Health Organization.

Instead of going to a doctor’s office or a community clinic, people rush to the hospitals to see specialists, even for fevers and headaches. This winter, flu-stricken patients camped out overnight with blankets in the corridors of several Beijing hospitals, according to state media.

Hospitals are understaffed and overwhelmed. Specialists are overworked, seeing as many as 200 patients a day.

Image

Nurses reviewing the patient list at the Gaoqiao community health service center in Shanghai. Hoping to get more people to use local clinics instead of hospitals, the government is paying specialists subsidies to staff them.CreditGilles Sabrié for The New York Times

And people are frustrated, with some resorting to violence. In China, attacks on doctors are so common that they have a name: “yi nao,” or “medical disturbance.”

In 2016, Mr. Xi unveiled the country’s first long-term blueprint to improve health care since the nation’s founding in 1949. Called Healthy China 2030, it pledged to bolster health innovation and make access to medical care more equal.

The deficiency in doctors has taken on more urgency as the Chinese government grapples with the mounting health problems of its vast population. Heart disease, strokes, diabetes and chronic lung disease account for 80 percent of deaths in China, according to a World Bank report in 2011.

Mao Qun’an, the spokesman for the National Health and Family Planning Commission, acknowledged that the hospitals could no longer meet the public’s needs.

“If you don’t get the grass roots right, then the medical problems in China cannot be solved,” Mr. Mao said. “So what we’re doing now is trying to return to the normal state.”

A Lack of Respect

On some mornings, Dr. Huang Dazhi, a general practitioner in Shanghai, rides his motorbike to a nursing home, where he treats about 40 patients a week. During lunchtime, he sprints back to his clinic to stock up on their medication and then heads back to the nursing home.

Afterward, he makes house calls to three or four people. On other days, he goes to his clinic, where he sees about 70 patients. At night, he doles out advice about high-blood-pressure medications and colds to his patients, who call him on his mobile phone.

Image

Dr. Huang Dazhi, a general practitioner in Shanghai, is paid about $1,340 a month — roughly his starting pay as a specialist 12 years ago.CreditGilles Sabrié for The New York Times

For all this, Dr. Huang is paid about $1,340 a month — roughly the same he was making starting out as a specialist in internal medicine 12 years ago.

“The social status of a general practitioner is not high enough,” Dr. Huang said, wearing a gray Nike T-shirt and jeans under his doctor’s coat. “It feels like there’s still a large gap when you compare us to specialists.”

In a country where pay is equated with respect, the public views family doctors as having a lower status and weaker credentials than specialists. Among nearly 18,000 doctors, only one-third thought that they were respected by the public, according to a 2017 survey by the Chinese Academy of Medical Sciences, Peking Union Medical College, Brigham and Women’s Hospital in Boston, Harvard Medical School, the Harvard T.H. Chan School of Public Health and the U.S. China Health Summit.

“There is no trust in the primary care system among the population because the good doctors don’t go there,” said Bernhard Schwartländer, a senior aide at the World Health Organization and its former representative to China. “They cannot make money.”

China once had a broad, if somewhat basic, primary health care system. “Barefoot doctors” roamed the countryside treating minor ailments. In the cities, people got their health care at clinics run by state-owned companies.

China’s “barefoot doctor” system was one of the Communist revolution’s most notable successes. In 1965, Chairman Mao, troubled by the lack of health care in the countryside, envisioned an army of people who spent half their time farming (many worked in the fields without shoes) and half their time treating patients. They weren’t doctors, but rather a sort of health care SWAT team. The authorities gave them a short training period — several months to a year — and a bag of limited medicine and equipment.

Average life expectancy in China increased to 63 years in 1970 from 44 in 1960, according to Theodore H. Tulchinsky and Elena A. Varavikova, authors of “The New Public Health,” a book about global medical care. The maternal mortality rate in rural China fell to 41.3 per 100,000 people from 150 per 100,000 before 1949, according to a 2008 article published by the World Health Organization. In the same period, the infant mortality rate fell to 18.6 per 1,000 from 200.

Image

A training session for family doctors at the Weifang community health service center in Shanghai.CreditGilles Sabrié for The New York Times

But the public was fed up that it could not get medical treatment whenever or wherever it wanted. People needed a referral to see a specialist in a hospital.

In the mid-1980s, the government lifted the barriers, allowing people to be treated in hospitals. At the same time, China began an economic overhaul that led to the dismantling of the entire system. Government subsidies were cut drastically, and hospitals had to come up with ways to generate profits.

As hospitals started investing in high-tech machines and expanded to meet their new financial needs, medical students were drawn to them. Many believed that being a specialist would guarantee them an “iron rice bowl,” a job that was secure with an extensive safety net that included housing and a pension.

Dr. Huang initially followed the more lucrative path. After graduating from medical school in 2006, he started working as an internist in a hospital in Shanghai.

But he kept seeing patients with simple aftercare needs like removing stitches, changing catheters and switching medication. “These things really should not be done by us specialists,” he said.

When Dr. Huang saw a newspaper article about general practitioners, he decided to enroll in a training program in 2007. He was inspired by his aunt, a “barefoot doctor” in Mingguang, a city in Anhui Province, one of the poorest regions in China.

As a boy, he had followed his aunt as she went to people’s homes to deliver babies and give injections. “After becoming a doctor, I’ve realized that the people’s needs for ‘barefoot doctors’ is still very much in demand,” he said.

Image

An electronic board at the entrance of Peking Union Hospital displays the number of doctors available and their specialty.CreditGilles Sabrié for The New York Times

Corruption and Backlash

In March, a doctor was killed by his patient’s husband. In November 2016, a man attacked a doctor after an argument over his daughter’s treatment. The month before, a father stabbed a pediatrician 15 times after his daughter died shortly after her birth. The doctor did not survive.

Dr. Zhao Lizhong, an emergency room doctor in Beijing, was sitting at a computer and writing a patient’s diagnosis when Lu Fu’ke plunged a knife into his neck in April 2012. Around him, patients screamed.

Hours earlier, Mr. Lu had stabbed Dr. Xing Zhimin, who had treated him for rhinitis, in the Peking University People’s Hospital and fled. Police officers arrested him in his hometown, Zhuozhou in the northern province of Hebei, later that month. Mr. Lu was sentenced to 13 years in jail.

“We know that this kind of thing can happen at any time,” Dr. Zhao said.

The root of the violence is all the same: a mistrust of the medical system.

It goes back to the market reforms under Deng Xiaoping in the 1980s. After the government cut back subsidies to hospitals, doctors were forced to find ways to make money. Many accepted kickbacks from drug companies and gifts from patients.

In a survey of more than 570 residents in Beijing, Shanghai and Guangzhou conducted in 2013 by Cheris Chan, a sociology professor at the University of Hong Kong, more than half said they and members of their family gave “red envelopes” as cash gifts to doctors for surgery during 2000-12.

Dr. Yu Ying, who worked as an emergency room doctor at Peking Union Hospital, one of China’s top hospitals, said she was once a valiant defender of her profession. On her widely followed account on Weibo, China’s version of Twitter, she pushed back against critics who called doctors “white-eyed wolves.”

Image

Dr. Yu Ying, who worked in Peking Union Hospital’s emergency room, said she had heard accounts of doctors who accepted thousands of dollars in kickbacks.CreditGilles Sabrié for The New York Times

“After I discovered the truth, I really had to give myself a slap in the face,” she said.

Dr. Yu said she had heard accounts from outpatient doctors who accepted thousands of dollars in kickbacks from drug companies — “cash that was bundled into plastic bags.”

“In the entire system, the majority of doctors accept red envelopes and kickbacks,” she said.

The corruption is endemic. GlaxoSmithKline paid a $500 million fine in 2014, the highest ever in China at the time, for giving kickbacks to doctors and hospitals that prescribed its medicines. Eli Lilly, Pfizer and other global drug giants have settled with regulators over similar behavior.

It all makes for a violent mix.

Many hospitals are taking measures to protect their workers. In the southern city of Guangzhou, the Zhongshan Hospital has hired taekwondo experts to teach doctors self-defense techniques. Hospitals in the eastern city of Jinan are paying private security companies for protection. Last year, the government pledged to station an adequate number of police officers in emergency departments, where most doctor-patient violence occurs.

Mr. Mao, the spokesman for the health ministry, said that while the figures for attacks on medical personnel looked alarming, they needed to be put in context. Chinese patients sought medical help eight billion times in 2016, a number that is equivalent to the world’s population, according to Mr. Mao. There were roughly 50,000 medical-related disputes in that period, a tiny fraction of the total number of health visits.

“Therefore, our judgment is the doctor-patient relationship in reality isn’t tense,” Mr. Mao said.

On the Front Line

If Beijing hopes to overhaul health care, it needs to persuade a skeptical public to stop going to the hospital for the sniffles.

To help change the culture, China is pushing each household to sign a contract with a family doctor by 2020 and subsidizing patients’ visits. General practitioners will also have the authority to make appointments directly with top specialists, rather than leaving patients to make their own at hospitals.

Such measures would make it easier for patients to transfer to top hospitals without a wait, while potentially giving them more personalized care from a doctor who knows their history. It could also cut down on costs, since it is cheaper under government insurance to see a family doctor.

Image

Dr. Zhu Min, who practices family medicine in Shanghai, splits her time between the local clinic, a hospital and patients’ homes.CreditGilles Sabrié for The New York Times

After the government’s directive, Dr. Yang Lan has signed up more than 200 patients, and monitors their health for about $1,220 a month. From her office in the Xinhua community health center, a run-down place with elderly patients milling about in the corridors, she keeps track of her patients with an Excel sheet on her computer. She said she had memorized their medical history and addresses.

Dr. Yang, 31, said her practice was largely free of grumpy patients and, as a result, “yi nao.” She sees 50 to 60 patients in a workday of about seven and a half hours. In the United States, a family doctor has 83 “patient encounters” in a 45-hour workweek, according to a 2017 survey by the American Academy of Family Physicians. That’s about 16 patients in a nine-hour workday.

The patients get something, too — a doctor who has time for them. Every three months, Dr. Yang has a face-to-face meeting with her patients, either during a house call or at her clinic. She’s available to dispense round-the-clock advice to her patients on WeChat, a popular messaging app in China. A patient is generally kept in the waiting room for a brief period and, if necessary, gets to talk with her for at least 15 minutes.

On a hot summer day, an elderly woman with white hair walked into Dr. Yang’s clinic. She has cardiovascular disease, and Dr. Yang told her to watch what she ate. Next, a man with diabetes dropped in. “Hey, you got a haircut!” Dr. Yang exclaimed. At one point, four retirees swarmed Dr. Yang’s room, talking over one another.

“I think she’s really warm and considerate,” said Cai Zhenghua, the patient with diabetes. He used to seek treatment at a hospital, he said, adding, “The time spent interacting with doctors here is much longer.”

The government aims to increase the number of general practitioners to two or three, and eventually five, for every 10,000 people, from 1.5 now. But to even have a chance of reaching its goals, China needs to train thousands of doctors who have no inkling of how a primary care system should function and little interest in leaving their cushy jobs in the public hospitals.

It is forcing hospital specialists to staff the community clinics every week and paying those doctors subsidies to do so. It is also trying to improve the bedside manner of doctors with government-backed training programs.

Image

Patients waiting for lab results at the Weifang clinic.CreditGilles Sabrié for The New York Times

In Shanghai, Du Zhaohui, then the head of the Weifang community health service center, introduced a test that uses mock patients to evaluate the care and skills of general practitioners. The doctors have 15 minutes to examine “patients.” The teachers use a checklist to grade the doctors on things like making “appropriate eye contact” and “responding appropriately to a patient’s emotions.”

At a recent test, one doctor, wearing crystal-studded Birkenstock sandals, examined a patient who had insufficient blood flow to the brain by swinging a tiny silver hammer, the equipment that is used for testing reflexes.

“That isn’t the right way,” Li Yaling, head of the center’s science and education department, said with a sigh. She said the doctor was probably too nervous and should have used a cotton swab to stroke the soles of the patient’s feet instead.

Dr. Zhu Shanzhu, a teacher in the program, said one of the main problems was that doctors did too few physical examinations in the community clinics. Many of them lean toward prescribing medicine instead. Clinical reasoning, too, is poor, she said.

In 2000, Dr. Zhu designed a course to train general practitioners in Shanghai’s Zhongshan Hospital, at the request of its director. Her first course was free. No one showed up.

Nearly two decades later, Dr. Zhu, 71, says that training is still insufficient and doctors do not spend enough time studying the latest research and techniques in their field.

“If there’s more money, the good people will come,” she said. “And a high economic status will elevate the social status.”

The government has pledged to increase the salaries of family doctors. But Dr. Zhu isn’t optimistic.

“All these ministries need to coordinate among themselves,” she said. “Our country’s affairs, you know, they aren’t easy.”

Follow Sui-Lee Wee on Twitter: @suilee.

Research was contributed by Zhang Tiantian, Zoe Mou, Qi Xu, Tang Yucheng, Amy Cheng and Elsie Chen.

A version of this article appears in print on

, on Page

A

1

of the New York edition

with the headline:

Lines, Bribes and Violence: A Health Care Crisis

. Order Reprints | Today’s Paper | Subscribe

Read More | https://www.nytimes.com/2018/09/30/business/china-health-care-doctors.html |

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’, in 2018-10-01 14:49:05

[internetbasic9]

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ https://ift.tt/2Iu12jN

Nature

Video

Homemade cancer drugs, violence in hospitals, doctor shortages: We take you inside China’s broken health care system to reveal how dire the situation is for over a billion people.Published OnSept. 30, 2018CreditCreditImage by Gilles Sabrié for The New York Times

BEIJING — Well before dawn, nearly a hundred people stood in line outside one of the capital’s top hospitals.

They were hoping to get an appointment with a specialist, a chance for access to the best health care in the country. Scalpers hawked medical visits for a fee, ignoring repeated crackdowns by the government.

A Beijing resident in line was trying to get his father in to see a neurologist. A senior lawmaker from Liaoning, a northeastern province, needed a second opinion on her daughter’s blood disorder.

Mao Ning, who was helping her friend get an appointment with a dermatologist, arrived at 4 a.m. She was in the middle of the line.

“There’s no choice — everyone comes to Beijing,” Ms. Mao, 40, said. “I think this is an unscientific approach and is not in keeping with our national conditions. We shouldn’t have people do this, right? There should be a reasonable system.”

The long lines, a standard feature of hospital visits in China, are a symptom of a health care system in crisis.

Image

Dr. Ye Minghao, a family practitioner in Shanghai, sees up to 80 patients a day. He enjoys his work, he said, but is unhappy about the lack of respect for his field.CreditGilles Sabrié for The New York Times

An economic boom over the past three decades has transformed China from a poor farming nation to the world’s second-largest economy. The cradle-to-grave system of socialized medicine has improved life expectancy and lowered maternal mortality rates.

But the system cannot adequately support China’s population of more than one billion people. The major gaps and inequalities threaten to undermine China’s progress, social stability and financial health — creating a serious challenge for President Xi Jinping and the Communist Party.

Then, there are the scandals. In July, hundreds of thousands of children were found to have been injected with faulty vaccines. The news angered the public, rattling confidence in the government and amplifying frustration with the health care system.

While the wealthy have access to the best care in top hospitals with foreign doctors, most people are relegated to overcrowded hospitals. In the countryside, people must rely on village clinics, or travel hundreds of miles to find the closest facility.

The country does not have a functioning primary care system, the first line of defense for illness and injury. China has one general practitioner for every 6,666 people, compared with the international standard of one for every 1,500 to 2,000 people, according to the World Health Organization.

Instead of going to a doctor’s office or a community clinic, people rush to the hospitals to see specialists, even for fevers and headaches. This winter, flu-stricken patients camped out overnight with blankets in the corridors of several Beijing hospitals, according to state media.

Hospitals are understaffed and overwhelmed. Specialists are overworked, seeing as many as 200 patients a day.

Image

Nurses reviewing the patient list at the Gaoqiao community health service center in Shanghai. Hoping to get more people to use local clinics instead of hospitals, the government is paying specialists subsidies to staff them.CreditGilles Sabrié for The New York Times

And people are frustrated, with some resorting to violence. In China, attacks on doctors are so common that they have a name: “yi nao,” or “medical disturbance.”

In 2016, Mr. Xi unveiled the country’s first long-term blueprint to improve health care since the nation’s founding in 1949. Called Healthy China 2030, it pledged to bolster health innovation and make access to medical care more equal.

The deficiency in doctors has taken on more urgency as the Chinese government grapples with the mounting health problems of its vast population. Heart disease, strokes, diabetes and chronic lung disease account for 80 percent of deaths in China, according to a World Bank report in 2011.

Mao Qun’an, the spokesman for the National Health and Family Planning Commission, acknowledged that the hospitals could no longer meet the public’s needs.

“If you don’t get the grass roots right, then the medical problems in China cannot be solved,” Mr. Mao said. “So what we’re doing now is trying to return to the normal state.”

A Lack of Respect

On some mornings, Dr. Huang Dazhi, a general practitioner in Shanghai, rides his motorbike to a nursing home, where he treats about 40 patients a week. During lunchtime, he sprints back to his clinic to stock up on their medication and then heads back to the nursing home.

Afterward, he makes house calls to three or four people. On other days, he goes to his clinic, where he sees about 70 patients. At night, he doles out advice about high-blood-pressure medications and colds to his patients, who call him on his mobile phone.

Image

Dr. Huang Dazhi, a general practitioner in Shanghai, is paid about $1,340 a month — roughly his starting pay as a specialist 12 years ago.CreditGilles Sabrié for The New York Times

For all this, Dr. Huang is paid about $1,340 a month — roughly the same he was making starting out as a specialist in internal medicine 12 years ago.

“The social status of a general practitioner is not high enough,” Dr. Huang said, wearing a gray Nike T-shirt and jeans under his doctor’s coat. “It feels like there’s still a large gap when you compare us to specialists.”

In a country where pay is equated with respect, the public views family doctors as having a lower status and weaker credentials than specialists. Among nearly 18,000 doctors, only one-third thought that they were respected by the public, according to a 2017 survey by the Chinese Academy of Medical Sciences, Peking Union Medical College, Brigham and Women’s Hospital in Boston, Harvard Medical School, the Harvard T.H. Chan School of Public Health and the U.S. China Health Summit.

“There is no trust in the primary care system among the population because the good doctors don’t go there,” said Bernhard Schwartländer, a senior aide at the World Health Organization and its former representative to China. “They cannot make money.”

China once had a broad, if somewhat basic, primary health care system. “Barefoot doctors” roamed the countryside treating minor ailments. In the cities, people got their health care at clinics run by state-owned companies.

China’s “barefoot doctor” system was one of the Communist revolution’s most notable successes. In 1965, Chairman Mao, troubled by the lack of health care in the countryside, envisioned an army of people who spent half their time farming (many worked in the fields without shoes) and half their time treating patients. They weren’t doctors, but rather a sort of health care SWAT team. The authorities gave them a short training period — several months to a year — and a bag of limited medicine and equipment.

Average life expectancy in China increased to 63 years in 1970 from 44 in 1960, according to Theodore H. Tulchinsky and Elena A. Varavikova, authors of “The New Public Health,” a book about global medical care. The maternal mortality rate in rural China fell to 41.3 per 100,000 people from 150 per 100,000 before 1949, according to a 2008 article published by the World Health Organization. In the same period, the infant mortality rate fell to 18.6 per 1,000 from 200.

Image

A training session for family doctors at the Weifang community health service center in Shanghai.CreditGilles Sabrié for The New York Times

But the public was fed up that it could not get medical treatment whenever or wherever it wanted. People needed a referral to see a specialist in a hospital.

In the mid-1980s, the government lifted the barriers, allowing people to be treated in hospitals. At the same time, China began an economic overhaul that led to the dismantling of the entire system. Government subsidies were cut drastically, and hospitals had to come up with ways to generate profits.

As hospitals started investing in high-tech machines and expanded to meet their new financial needs, medical students were drawn to them. Many believed that being a specialist would guarantee them an “iron rice bowl,” a job that was secure with an extensive safety net that included housing and a pension.

Dr. Huang initially followed the more lucrative path. After graduating from medical school in 2006, he started working as an internist in a hospital in Shanghai.

But he kept seeing patients with simple aftercare needs like removing stitches, changing catheters and switching medication. “These things really should not be done by us specialists,” he said.

When Dr. Huang saw a newspaper article about general practitioners, he decided to enroll in a training program in 2007. He was inspired by his aunt, a “barefoot doctor” in Mingguang, a city in Anhui Province, one of the poorest regions in China.

As a boy, he had followed his aunt as she went to people’s homes to deliver babies and give injections. “After becoming a doctor, I’ve realized that the people’s needs for ‘barefoot doctors’ is still very much in demand,” he said.

Image

An electronic board at the entrance of Peking Union Hospital displays the number of doctors available and their specialty.CreditGilles Sabrié for The New York Times

Corruption and Backlash

In March, a doctor was killed by his patient’s husband. In November 2016, a man attacked a doctor after an argument over his daughter’s treatment. The month before, a father stabbed a pediatrician 15 times after his daughter died shortly after her birth. The doctor did not survive.

Dr. Zhao Lizhong, an emergency room doctor in Beijing, was sitting at a computer and writing a patient’s diagnosis when Lu Fu’ke plunged a knife into his neck in April 2012. Around him, patients screamed.

Hours earlier, Mr. Lu had stabbed Dr. Xing Zhimin, who had treated him for rhinitis, in the Peking University People’s Hospital and fled. Police officers arrested him in his hometown, Zhuozhou in the northern province of Hebei, later that month. Mr. Lu was sentenced to 13 years in jail.

“We know that this kind of thing can happen at any time,” Dr. Zhao said.

The root of the violence is all the same: a mistrust of the medical system.

It goes back to the market reforms under Deng Xiaoping in the 1980s. After the government cut back subsidies to hospitals, doctors were forced to find ways to make money. Many accepted kickbacks from drug companies and gifts from patients.

In a survey of more than 570 residents in Beijing, Shanghai and Guangzhou conducted in 2013 by Cheris Chan, a sociology professor at the University of Hong Kong, more than half said they and members of their family gave “red envelopes” as cash gifts to doctors for surgery during 2000-12.

Dr. Yu Ying, who worked as an emergency room doctor at Peking Union Hospital, one of China’s top hospitals, said she was once a valiant defender of her profession. On her widely followed account on Weibo, China’s version of Twitter, she pushed back against critics who called doctors “white-eyed wolves.”

Image

Dr. Yu Ying, who worked in Peking Union Hospital’s emergency room, said she had heard accounts of doctors who accepted thousands of dollars in kickbacks.CreditGilles Sabrié for The New York Times

“After I discovered the truth, I really had to give myself a slap in the face,” she said.

Dr. Yu said she had heard accounts from outpatient doctors who accepted thousands of dollars in kickbacks from drug companies — “cash that was bundled into plastic bags.”

“In the entire system, the majority of doctors accept red envelopes and kickbacks,” she said.

The corruption is endemic. GlaxoSmithKline paid a $500 million fine in 2014, the highest ever in China at the time, for giving kickbacks to doctors and hospitals that prescribed its medicines. Eli Lilly, Pfizer and other global drug giants have settled with regulators over similar behavior.

It all makes for a violent mix.

Many hospitals are taking measures to protect their workers. In the southern city of Guangzhou, the Zhongshan Hospital has hired taekwondo experts to teach doctors self-defense techniques. Hospitals in the eastern city of Jinan are paying private security companies for protection. Last year, the government pledged to station an adequate number of police officers in emergency departments, where most doctor-patient violence occurs.

Mr. Mao, the spokesman for the health ministry, said that while the figures for attacks on medical personnel looked alarming, they needed to be put in context. Chinese patients sought medical help eight billion times in 2016, a number that is equivalent to the world’s population, according to Mr. Mao. There were roughly 50,000 medical-related disputes in that period, a tiny fraction of the total number of health visits.

“Therefore, our judgment is the doctor-patient relationship in reality isn’t tense,” Mr. Mao said.

On the Front Line

If Beijing hopes to overhaul health care, it needs to persuade a skeptical public to stop going to the hospital for the sniffles.

To help change the culture, China is pushing each household to sign a contract with a family doctor by 2020 and subsidizing patients’ visits. General practitioners will also have the authority to make appointments directly with top specialists, rather than leaving patients to make their own at hospitals.

Such measures would make it easier for patients to transfer to top hospitals without a wait, while potentially giving them more personalized care from a doctor who knows their history. It could also cut down on costs, since it is cheaper under government insurance to see a family doctor.

Image

Dr. Zhu Min, who practices family medicine in Shanghai, splits her time between the local clinic, a hospital and patients’ homes.CreditGilles Sabrié for The New York Times

After the government’s directive, Dr. Yang Lan has signed up more than 200 patients, and monitors their health for about $1,220 a month. From her office in the Xinhua community health center, a run-down place with elderly patients milling about in the corridors, she keeps track of her patients with an Excel sheet on her computer. She said she had memorized their medical history and addresses.

Dr. Yang, 31, said her practice was largely free of grumpy patients and, as a result, “yi nao.” She sees 50 to 60 patients in a workday of about seven and a half hours. In the United States, a family doctor has 83 “patient encounters” in a 45-hour workweek, according to a 2017 survey by the American Academy of Family Physicians. That’s about 16 patients in a nine-hour workday.

The patients get something, too — a doctor who has time for them. Every three months, Dr. Yang has a face-to-face meeting with her patients, either during a house call or at her clinic. She’s available to dispense round-the-clock advice to her patients on WeChat, a popular messaging app in China. A patient is generally kept in the waiting room for a brief period and, if necessary, gets to talk with her for at least 15 minutes.

On a hot summer day, an elderly woman with white hair walked into Dr. Yang’s clinic. She has cardiovascular disease, and Dr. Yang told her to watch what she ate. Next, a man with diabetes dropped in. “Hey, you got a haircut!” Dr. Yang exclaimed. At one point, four retirees swarmed Dr. Yang’s room, talking over one another.

“I think she’s really warm and considerate,” said Cai Zhenghua, the patient with diabetes. He used to seek treatment at a hospital, he said, adding, “The time spent interacting with doctors here is much longer.”

The government aims to increase the number of general practitioners to two or three, and eventually five, for every 10,000 people, from 1.5 now. But to even have a chance of reaching its goals, China needs to train thousands of doctors who have no inkling of how a primary care system should function and little interest in leaving their cushy jobs in the public hospitals.

It is forcing hospital specialists to staff the community clinics every week and paying those doctors subsidies to do so. It is also trying to improve the bedside manner of doctors with government-backed training programs.

Image

Patients waiting for lab results at the Weifang clinic.CreditGilles Sabrié for The New York Times

In Shanghai, Du Zhaohui, then the head of the Weifang community health service center, introduced a test that uses mock patients to evaluate the care and skills of general practitioners. The doctors have 15 minutes to examine “patients.” The teachers use a checklist to grade the doctors on things like making “appropriate eye contact” and “responding appropriately to a patient’s emotions.”

At a recent test, one doctor, wearing crystal-studded Birkenstock sandals, examined a patient who had insufficient blood flow to the brain by swinging a tiny silver hammer, the equipment that is used for testing reflexes.

“That isn’t the right way,” Li Yaling, head of the center’s science and education department, said with a sigh. She said the doctor was probably too nervous and should have used a cotton swab to stroke the soles of the patient’s feet instead.

Dr. Zhu Shanzhu, a teacher in the program, said one of the main problems was that doctors did too few physical examinations in the community clinics. Many of them lean toward prescribing medicine instead. Clinical reasoning, too, is poor, she said.

In 2000, Dr. Zhu designed a course to train general practitioners in Shanghai’s Zhongshan Hospital, at the request of its director. Her first course was free. No one showed up.

Nearly two decades later, Dr. Zhu, 71, says that training is still insufficient and doctors do not spend enough time studying the latest research and techniques in their field.

“If there’s more money, the good people will come,” she said. “And a high economic status will elevate the social status.”

The government has pledged to increase the salaries of family doctors. But Dr. Zhu isn’t optimistic.

“All these ministries need to coordinate among themselves,” she said. “Our country’s affairs, you know, they aren’t easy.”

Follow Sui-Lee Wee on Twitter: @suilee.

Research was contributed by Zhang Tiantian, Zoe Mou, Qi Xu, Tang Yucheng, Amy Cheng and Elsie Chen.

A version of this article appears in print on

, on Page

A

1

of the New York edition

with the headline:

Lines, Bribes and Violence: A Health Care Crisis

. Order Reprints | Today’s Paper | Subscribe

Read More | https://ift.tt/2DJzbgR |

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’, in 2018-10-01 14:49:05

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Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ http://www.nature-business.com/nature-chinas-health-care-crisis-lines-before-dawn-violence-and-no-trust/

Nature

Video

Homemade cancer drugs, violence in hospitals, doctor shortages: We take you inside China’s broken health care system to reveal how dire the situation is for over a billion people.Published OnSept. 30, 2018CreditCreditImage by Gilles Sabrié for The New York Times

BEIJING — Well before dawn, nearly a hundred people stood in line outside one of the capital’s top hospitals.

They were hoping to get an appointment with a specialist, a chance for access to the best health care in the country. Scalpers hawked medical visits for a fee, ignoring repeated crackdowns by the government.

A Beijing resident in line was trying to get his father in to see a neurologist. A senior lawmaker from Liaoning, a northeastern province, needed a second opinion on her daughter’s blood disorder.

Mao Ning, who was helping her friend get an appointment with a dermatologist, arrived at 4 a.m. She was in the middle of the line.

“There’s no choice — everyone comes to Beijing,” Ms. Mao, 40, said. “I think this is an unscientific approach and is not in keeping with our national conditions. We shouldn’t have people do this, right? There should be a reasonable system.”

The long lines, a standard feature of hospital visits in China, are a symptom of a health care system in crisis.

Image

Dr. Ye Minghao, a family practitioner in Shanghai, sees up to 80 patients a day. He enjoys his work, he said, but is unhappy about the lack of respect for his field.CreditGilles Sabrié for The New York Times

An economic boom over the past three decades has transformed China from a poor farming nation to the world’s second-largest economy. The cradle-to-grave system of socialized medicine has improved life expectancy and lowered maternal mortality rates.

But the system cannot adequately support China’s population of more than one billion people. The major gaps and inequalities threaten to undermine China’s progress, social stability and financial health — creating a serious challenge for President Xi Jinping and the Communist Party.

Then, there are the scandals. In July, hundreds of thousands of children were found to have been injected with faulty vaccines. The news angered the public, rattling confidence in the government and amplifying frustration with the health care system.

While the wealthy have access to the best care in top hospitals with foreign doctors, most people are relegated to overcrowded hospitals. In the countryside, people must rely on village clinics, or travel hundreds of miles to find the closest facility.

The country does not have a functioning primary care system, the first line of defense for illness and injury. China has one general practitioner for every 6,666 people, compared with the international standard of one for every 1,500 to 2,000 people, according to the World Health Organization.

Instead of going to a doctor’s office or a community clinic, people rush to the hospitals to see specialists, even for fevers and headaches. This winter, flu-stricken patients camped out overnight with blankets in the corridors of several Beijing hospitals, according to state media.

Hospitals are understaffed and overwhelmed. Specialists are overworked, seeing as many as 200 patients a day.

Image

Nurses reviewing the patient list at the Gaoqiao community health service center in Shanghai. Hoping to get more people to use local clinics instead of hospitals, the government is paying specialists subsidies to staff them.CreditGilles Sabrié for The New York Times

And people are frustrated, with some resorting to violence. In China, attacks on doctors are so common that they have a name: “yi nao,” or “medical disturbance.”

In 2016, Mr. Xi unveiled the country’s first long-term blueprint to improve health care since the nation’s founding in 1949. Called Healthy China 2030, it pledged to bolster health innovation and make access to medical care more equal.

The deficiency in doctors has taken on more urgency as the Chinese government grapples with the mounting health problems of its vast population. Heart disease, strokes, diabetes and chronic lung disease account for 80 percent of deaths in China, according to a World Bank report in 2011.

Mao Qun’an, the spokesman for the National Health and Family Planning Commission, acknowledged that the hospitals could no longer meet the public’s needs.

“If you don’t get the grass roots right, then the medical problems in China cannot be solved,” Mr. Mao said. “So what we’re doing now is trying to return to the normal state.”

A Lack of Respect

On some mornings, Dr. Huang Dazhi, a general practitioner in Shanghai, rides his motorbike to a nursing home, where he treats about 40 patients a week. During lunchtime, he sprints back to his clinic to stock up on their medication and then heads back to the nursing home.

Afterward, he makes house calls to three or four people. On other days, he goes to his clinic, where he sees about 70 patients. At night, he doles out advice about high-blood-pressure medications and colds to his patients, who call him on his mobile phone.

Image

Dr. Huang Dazhi, a general practitioner in Shanghai, is paid about $1,340 a month — roughly his starting pay as a specialist 12 years ago.CreditGilles Sabrié for The New York Times

For all this, Dr. Huang is paid about $1,340 a month — roughly the same he was making starting out as a specialist in internal medicine 12 years ago.

“The social status of a general practitioner is not high enough,” Dr. Huang said, wearing a gray Nike T-shirt and jeans under his doctor’s coat. “It feels like there’s still a large gap when you compare us to specialists.”

In a country where pay is equated with respect, the public views family doctors as having a lower status and weaker credentials than specialists. Among nearly 18,000 doctors, only one-third thought that they were respected by the public, according to a 2017 survey by the Chinese Academy of Medical Sciences, Peking Union Medical College, Brigham and Women’s Hospital in Boston, Harvard Medical School, the Harvard T.H. Chan School of Public Health and the U.S. China Health Summit.

“There is no trust in the primary care system among the population because the good doctors don’t go there,” said Bernhard Schwartländer, a senior aide at the World Health Organization and its former representative to China. “They cannot make money.”

China once had a broad, if somewhat basic, primary health care system. “Barefoot doctors” roamed the countryside treating minor ailments. In the cities, people got their health care at clinics run by state-owned companies.

China’s “barefoot doctor” system was one of the Communist revolution’s most notable successes. In 1965, Chairman Mao, troubled by the lack of health care in the countryside, envisioned an army of people who spent half their time farming (many worked in the fields without shoes) and half their time treating patients. They weren’t doctors, but rather a sort of health care SWAT team. The authorities gave them a short training period — several months to a year — and a bag of limited medicine and equipment.

Average life expectancy in China increased to 63 years in 1970 from 44 in 1960, according to Theodore H. Tulchinsky and Elena A. Varavikova, authors of “The New Public Health,” a book about global medical care. The maternal mortality rate in rural China fell to 41.3 per 100,000 people from 150 per 100,000 before 1949, according to a 2008 article published by the World Health Organization. In the same period, the infant mortality rate fell to 18.6 per 1,000 from 200.

Image

A training session for family doctors at the Weifang community health service center in Shanghai.CreditGilles Sabrié for The New York Times

But the public was fed up that it could not get medical treatment whenever or wherever it wanted. People needed a referral to see a specialist in a hospital.

In the mid-1980s, the government lifted the barriers, allowing people to be treated in hospitals. At the same time, China began an economic overhaul that led to the dismantling of the entire system. Government subsidies were cut drastically, and hospitals had to come up with ways to generate profits.

As hospitals started investing in high-tech machines and expanded to meet their new financial needs, medical students were drawn to them. Many believed that being a specialist would guarantee them an “iron rice bowl,” a job that was secure with an extensive safety net that included housing and a pension.

Dr. Huang initially followed the more lucrative path. After graduating from medical school in 2006, he started working as an internist in a hospital in Shanghai.

But he kept seeing patients with simple aftercare needs like removing stitches, changing catheters and switching medication. “These things really should not be done by us specialists,” he said.

When Dr. Huang saw a newspaper article about general practitioners, he decided to enroll in a training program in 2007. He was inspired by his aunt, a “barefoot doctor” in Mingguang, a city in Anhui Province, one of the poorest regions in China.

As a boy, he had followed his aunt as she went to people’s homes to deliver babies and give injections. “After becoming a doctor, I’ve realized that the people’s needs for ‘barefoot doctors’ is still very much in demand,” he said.

Image

An electronic board at the entrance of Peking Union Hospital displays the number of doctors available and their specialty.CreditGilles Sabrié for The New York Times

Corruption and Backlash

In March, a doctor was killed by his patient’s husband. In November 2016, a man attacked a doctor after an argument over his daughter’s treatment. The month before, a father stabbed a pediatrician 15 times after his daughter died shortly after her birth. The doctor did not survive.

Dr. Zhao Lizhong, an emergency room doctor in Beijing, was sitting at a computer and writing a patient’s diagnosis when Lu Fu’ke plunged a knife into his neck in April 2012. Around him, patients screamed.

Hours earlier, Mr. Lu had stabbed Dr. Xing Zhimin, who had treated him for rhinitis, in the Peking University People’s Hospital and fled. Police officers arrested him in his hometown, Zhuozhou in the northern province of Hebei, later that month. Mr. Lu was sentenced to 13 years in jail.

“We know that this kind of thing can happen at any time,” Dr. Zhao said.

The root of the violence is all the same: a mistrust of the medical system.

It goes back to the market reforms under Deng Xiaoping in the 1980s. After the government cut back subsidies to hospitals, doctors were forced to find ways to make money. Many accepted kickbacks from drug companies and gifts from patients.

In a survey of more than 570 residents in Beijing, Shanghai and Guangzhou conducted in 2013 by Cheris Chan, a sociology professor at the University of Hong Kong, more than half said they and members of their family gave “red envelopes” as cash gifts to doctors for surgery during 2000-12.

Dr. Yu Ying, who worked as an emergency room doctor at Peking Union Hospital, one of China’s top hospitals, said she was once a valiant defender of her profession. On her widely followed account on Weibo, China’s version of Twitter, she pushed back against critics who called doctors “white-eyed wolves.”

Image

Dr. Yu Ying, who worked in Peking Union Hospital’s emergency room, said she had heard accounts of doctors who accepted thousands of dollars in kickbacks.CreditGilles Sabrié for The New York Times

“After I discovered the truth, I really had to give myself a slap in the face,” she said.

Dr. Yu said she had heard accounts from outpatient doctors who accepted thousands of dollars in kickbacks from drug companies — “cash that was bundled into plastic bags.”

“In the entire system, the majority of doctors accept red envelopes and kickbacks,” she said.

The corruption is endemic. GlaxoSmithKline paid a $500 million fine in 2014, the highest ever in China at the time, for giving kickbacks to doctors and hospitals that prescribed its medicines. Eli Lilly, Pfizer and other global drug giants have settled with regulators over similar behavior.

It all makes for a violent mix.

Many hospitals are taking measures to protect their workers. In the southern city of Guangzhou, the Zhongshan Hospital has hired taekwondo experts to teach doctors self-defense techniques. Hospitals in the eastern city of Jinan are paying private security companies for protection. Last year, the government pledged to station an adequate number of police officers in emergency departments, where most doctor-patient violence occurs.

Mr. Mao, the spokesman for the health ministry, said that while the figures for attacks on medical personnel looked alarming, they needed to be put in context. Chinese patients sought medical help eight billion times in 2016, a number that is equivalent to the world’s population, according to Mr. Mao. There were roughly 50,000 medical-related disputes in that period, a tiny fraction of the total number of health visits.

“Therefore, our judgment is the doctor-patient relationship in reality isn’t tense,” Mr. Mao said.

On the Front Line

If Beijing hopes to overhaul health care, it needs to persuade a skeptical public to stop going to the hospital for the sniffles.

To help change the culture, China is pushing each household to sign a contract with a family doctor by 2020 and subsidizing patients’ visits. General practitioners will also have the authority to make appointments directly with top specialists, rather than leaving patients to make their own at hospitals.

Such measures would make it easier for patients to transfer to top hospitals without a wait, while potentially giving them more personalized care from a doctor who knows their history. It could also cut down on costs, since it is cheaper under government insurance to see a family doctor.

Image

Dr. Zhu Min, who practices family medicine in Shanghai, splits her time between the local clinic, a hospital and patients’ homes.CreditGilles Sabrié for The New York Times

After the government’s directive, Dr. Yang Lan has signed up more than 200 patients, and monitors their health for about $1,220 a month. From her office in the Xinhua community health center, a run-down place with elderly patients milling about in the corridors, she keeps track of her patients with an Excel sheet on her computer. She said she had memorized their medical history and addresses.

Dr. Yang, 31, said her practice was largely free of grumpy patients and, as a result, “yi nao.” She sees 50 to 60 patients in a workday of about seven and a half hours. In the United States, a family doctor has 83 “patient encounters” in a 45-hour workweek, according to a 2017 survey by the American Academy of Family Physicians. That’s about 16 patients in a nine-hour workday.

The patients get something, too — a doctor who has time for them. Every three months, Dr. Yang has a face-to-face meeting with her patients, either during a house call or at her clinic. She’s available to dispense round-the-clock advice to her patients on WeChat, a popular messaging app in China. A patient is generally kept in the waiting room for a brief period and, if necessary, gets to talk with her for at least 15 minutes.

On a hot summer day, an elderly woman with white hair walked into Dr. Yang’s clinic. She has cardiovascular disease, and Dr. Yang told her to watch what she ate. Next, a man with diabetes dropped in. “Hey, you got a haircut!” Dr. Yang exclaimed. At one point, four retirees swarmed Dr. Yang’s room, talking over one another.

“I think she’s really warm and considerate,” said Cai Zhenghua, the patient with diabetes. He used to seek treatment at a hospital, he said, adding, “The time spent interacting with doctors here is much longer.”

The government aims to increase the number of general practitioners to two or three, and eventually five, for every 10,000 people, from 1.5 now. But to even have a chance of reaching its goals, China needs to train thousands of doctors who have no inkling of how a primary care system should function and little interest in leaving their cushy jobs in the public hospitals.

It is forcing hospital specialists to staff the community clinics every week and paying those doctors subsidies to do so. It is also trying to improve the bedside manner of doctors with government-backed training programs.

Image

Patients waiting for lab results at the Weifang clinic.CreditGilles Sabrié for The New York Times

In Shanghai, Du Zhaohui, then the head of the Weifang community health service center, introduced a test that uses mock patients to evaluate the care and skills of general practitioners. The doctors have 15 minutes to examine “patients.” The teachers use a checklist to grade the doctors on things like making “appropriate eye contact” and “responding appropriately to a patient’s emotions.”

At a recent test, one doctor, wearing crystal-studded Birkenstock sandals, examined a patient who had insufficient blood flow to the brain by swinging a tiny silver hammer, the equipment that is used for testing reflexes.

“That isn’t the right way,” Li Yaling, head of the center’s science and education department, said with a sigh. She said the doctor was probably too nervous and should have used a cotton swab to stroke the soles of the patient’s feet instead.

Dr. Zhu Shanzhu, a teacher in the program, said one of the main problems was that doctors did too few physical examinations in the community clinics. Many of them lean toward prescribing medicine instead. Clinical reasoning, too, is poor, she said.

In 2000, Dr. Zhu designed a course to train general practitioners in Shanghai’s Zhongshan Hospital, at the request of its director. Her first course was free. No one showed up.

Nearly two decades later, Dr. Zhu, 71, says that training is still insufficient and doctors do not spend enough time studying the latest research and techniques in their field.

“If there’s more money, the good people will come,” she said. “And a high economic status will elevate the social status.”

The government has pledged to increase the salaries of family doctors. But Dr. Zhu isn’t optimistic.

“All these ministries need to coordinate among themselves,” she said. “Our country’s affairs, you know, they aren’t easy.”

Follow Sui-Lee Wee on Twitter: @suilee.

Research was contributed by Zhang Tiantian, Zoe Mou, Qi Xu, Tang Yucheng, Amy Cheng and Elsie Chen.

A version of this article appears in print on

, on Page

A

1

of the New York edition

with the headline:

Lines, Bribes and Violence: A Health Care Crisis

. Order Reprints | Today’s Paper | Subscribe

Read More | https://www.nytimes.com/2018/09/30/business/china-health-care-doctors.html |

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’, in 2018-10-01 14:49:05

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Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ http://www.nature-business.com/nature-chinas-health-care-crisis-lines-before-dawn-violence-and-no-trust/

Nature

Video

Homemade cancer drugs, violence in hospitals, doctor shortages: We take you inside China’s broken health care system to reveal how dire the situation is for over a billion people.Published OnSept. 30, 2018CreditCreditImage by Gilles Sabrié for The New York Times

BEIJING — Well before dawn, nearly a hundred people stood in line outside one of the capital’s top hospitals.

They were hoping to get an appointment with a specialist, a chance for access to the best health care in the country. Scalpers hawked medical visits for a fee, ignoring repeated crackdowns by the government.

A Beijing resident in line was trying to get his father in to see a neurologist. A senior lawmaker from Liaoning, a northeastern province, needed a second opinion on her daughter’s blood disorder.

Mao Ning, who was helping her friend get an appointment with a dermatologist, arrived at 4 a.m. She was in the middle of the line.

“There’s no choice — everyone comes to Beijing,” Ms. Mao, 40, said. “I think this is an unscientific approach and is not in keeping with our national conditions. We shouldn’t have people do this, right? There should be a reasonable system.”

The long lines, a standard feature of hospital visits in China, are a symptom of a health care system in crisis.

Image

Dr. Ye Minghao, a family practitioner in Shanghai, sees up to 80 patients a day. He enjoys his work, he said, but is unhappy about the lack of respect for his field.CreditGilles Sabrié for The New York Times

An economic boom over the past three decades has transformed China from a poor farming nation to the world’s second-largest economy. The cradle-to-grave system of socialized medicine has improved life expectancy and lowered maternal mortality rates.

But the system cannot adequately support China’s population of more than one billion people. The major gaps and inequalities threaten to undermine China’s progress, social stability and financial health — creating a serious challenge for President Xi Jinping and the Communist Party.

Then, there are the scandals. In July, hundreds of thousands of children were found to have been injected with faulty vaccines. The news angered the public, rattling confidence in the government and amplifying frustration with the health care system.

While the wealthy have access to the best care in top hospitals with foreign doctors, most people are relegated to overcrowded hospitals. In the countryside, people must rely on village clinics, or travel hundreds of miles to find the closest facility.

The country does not have a functioning primary care system, the first line of defense for illness and injury. China has one general practitioner for every 6,666 people, compared with the international standard of one for every 1,500 to 2,000 people, according to the World Health Organization.

Instead of going to a doctor’s office or a community clinic, people rush to the hospitals to see specialists, even for fevers and headaches. This winter, flu-stricken patients camped out overnight with blankets in the corridors of several Beijing hospitals, according to state media.

Hospitals are understaffed and overwhelmed. Specialists are overworked, seeing as many as 200 patients a day.

Image

Nurses reviewing the patient list at the Gaoqiao community health service center in Shanghai. Hoping to get more people to use local clinics instead of hospitals, the government is paying specialists subsidies to staff them.CreditGilles Sabrié for The New York Times

And people are frustrated, with some resorting to violence. In China, attacks on doctors are so common that they have a name: “yi nao,” or “medical disturbance.”

In 2016, Mr. Xi unveiled the country’s first long-term blueprint to improve health care since the nation’s founding in 1949. Called Healthy China 2030, it pledged to bolster health innovation and make access to medical care more equal.

The deficiency in doctors has taken on more urgency as the Chinese government grapples with the mounting health problems of its vast population. Heart disease, strokes, diabetes and chronic lung disease account for 80 percent of deaths in China, according to a World Bank report in 2011.

Mao Qun’an, the spokesman for the National Health and Family Planning Commission, acknowledged that the hospitals could no longer meet the public’s needs.

“If you don’t get the grass roots right, then the medical problems in China cannot be solved,” Mr. Mao said. “So what we’re doing now is trying to return to the normal state.”

A Lack of Respect

On some mornings, Dr. Huang Dazhi, a general practitioner in Shanghai, rides his motorbike to a nursing home, where he treats about 40 patients a week. During lunchtime, he sprints back to his clinic to stock up on their medication and then heads back to the nursing home.

Afterward, he makes house calls to three or four people. On other days, he goes to his clinic, where he sees about 70 patients. At night, he doles out advice about high-blood-pressure medications and colds to his patients, who call him on his mobile phone.

Image

Dr. Huang Dazhi, a general practitioner in Shanghai, is paid about $1,340 a month — roughly his starting pay as a specialist 12 years ago.CreditGilles Sabrié for The New York Times

For all this, Dr. Huang is paid about $1,340 a month — roughly the same he was making starting out as a specialist in internal medicine 12 years ago.

“The social status of a general practitioner is not high enough,” Dr. Huang said, wearing a gray Nike T-shirt and jeans under his doctor’s coat. “It feels like there’s still a large gap when you compare us to specialists.”

In a country where pay is equated with respect, the public views family doctors as having a lower status and weaker credentials than specialists. Among nearly 18,000 doctors, only one-third thought that they were respected by the public, according to a 2017 survey by the Chinese Academy of Medical Sciences, Peking Union Medical College, Brigham and Women’s Hospital in Boston, Harvard Medical School, the Harvard T.H. Chan School of Public Health and the U.S. China Health Summit.

“There is no trust in the primary care system among the population because the good doctors don’t go there,” said Bernhard Schwartländer, a senior aide at the World Health Organization and its former representative to China. “They cannot make money.”

China once had a broad, if somewhat basic, primary health care system. “Barefoot doctors” roamed the countryside treating minor ailments. In the cities, people got their health care at clinics run by state-owned companies.

China’s “barefoot doctor” system was one of the Communist revolution’s most notable successes. In 1965, Chairman Mao, troubled by the lack of health care in the countryside, envisioned an army of people who spent half their time farming (many worked in the fields without shoes) and half their time treating patients. They weren’t doctors, but rather a sort of health care SWAT team. The authorities gave them a short training period — several months to a year — and a bag of limited medicine and equipment.

Average life expectancy in China increased to 63 years in 1970 from 44 in 1960, according to Theodore H. Tulchinsky and Elena A. Varavikova, authors of “The New Public Health,” a book about global medical care. The maternal mortality rate in rural China fell to 41.3 per 100,000 people from 150 per 100,000 before 1949, according to a 2008 article published by the World Health Organization. In the same period, the infant mortality rate fell to 18.6 per 1,000 from 200.

Image

A training session for family doctors at the Weifang community health service center in Shanghai.CreditGilles Sabrié for The New York Times

But the public was fed up that it could not get medical treatment whenever or wherever it wanted. People needed a referral to see a specialist in a hospital.

In the mid-1980s, the government lifted the barriers, allowing people to be treated in hospitals. At the same time, China began an economic overhaul that led to the dismantling of the entire system. Government subsidies were cut drastically, and hospitals had to come up with ways to generate profits.

As hospitals started investing in high-tech machines and expanded to meet their new financial needs, medical students were drawn to them. Many believed that being a specialist would guarantee them an “iron rice bowl,” a job that was secure with an extensive safety net that included housing and a pension.

Dr. Huang initially followed the more lucrative path. After graduating from medical school in 2006, he started working as an internist in a hospital in Shanghai.

But he kept seeing patients with simple aftercare needs like removing stitches, changing catheters and switching medication. “These things really should not be done by us specialists,” he said.

When Dr. Huang saw a newspaper article about general practitioners, he decided to enroll in a training program in 2007. He was inspired by his aunt, a “barefoot doctor” in Mingguang, a city in Anhui Province, one of the poorest regions in China.

As a boy, he had followed his aunt as she went to people’s homes to deliver babies and give injections. “After becoming a doctor, I’ve realized that the people’s needs for ‘barefoot doctors’ is still very much in demand,” he said.

Image

An electronic board at the entrance of Peking Union Hospital displays the number of doctors available and their specialty.CreditGilles Sabrié for The New York Times

Corruption and Backlash

In March, a doctor was killed by his patient’s husband. In November 2016, a man attacked a doctor after an argument over his daughter’s treatment. The month before, a father stabbed a pediatrician 15 times after his daughter died shortly after her birth. The doctor did not survive.

Dr. Zhao Lizhong, an emergency room doctor in Beijing, was sitting at a computer and writing a patient’s diagnosis when Lu Fu’ke plunged a knife into his neck in April 2012. Around him, patients screamed.

Hours earlier, Mr. Lu had stabbed Dr. Xing Zhimin, who had treated him for rhinitis, in the Peking University People’s Hospital and fled. Police officers arrested him in his hometown, Zhuozhou in the northern province of Hebei, later that month. Mr. Lu was sentenced to 13 years in jail.

“We know that this kind of thing can happen at any time,” Dr. Zhao said.

The root of the violence is all the same: a mistrust of the medical system.

It goes back to the market reforms under Deng Xiaoping in the 1980s. After the government cut back subsidies to hospitals, doctors were forced to find ways to make money. Many accepted kickbacks from drug companies and gifts from patients.

In a survey of more than 570 residents in Beijing, Shanghai and Guangzhou conducted in 2013 by Cheris Chan, a sociology professor at the University of Hong Kong, more than half said they and members of their family gave “red envelopes” as cash gifts to doctors for surgery during 2000-12.

Dr. Yu Ying, who worked as an emergency room doctor at Peking Union Hospital, one of China’s top hospitals, said she was once a valiant defender of her profession. On her widely followed account on Weibo, China’s version of Twitter, she pushed back against critics who called doctors “white-eyed wolves.”

Image

Dr. Yu Ying, who worked in Peking Union Hospital’s emergency room, said she had heard accounts of doctors who accepted thousands of dollars in kickbacks.CreditGilles Sabrié for The New York Times

“After I discovered the truth, I really had to give myself a slap in the face,” she said.

Dr. Yu said she had heard accounts from outpatient doctors who accepted thousands of dollars in kickbacks from drug companies — “cash that was bundled into plastic bags.”

“In the entire system, the majority of doctors accept red envelopes and kickbacks,” she said.

The corruption is endemic. GlaxoSmithKline paid a $500 million fine in 2014, the highest ever in China at the time, for giving kickbacks to doctors and hospitals that prescribed its medicines. Eli Lilly, Pfizer and other global drug giants have settled with regulators over similar behavior.

It all makes for a violent mix.

Many hospitals are taking measures to protect their workers. In the southern city of Guangzhou, the Zhongshan Hospital has hired taekwondo experts to teach doctors self-defense techniques. Hospitals in the eastern city of Jinan are paying private security companies for protection. Last year, the government pledged to station an adequate number of police officers in emergency departments, where most doctor-patient violence occurs.

Mr. Mao, the spokesman for the health ministry, said that while the figures for attacks on medical personnel looked alarming, they needed to be put in context. Chinese patients sought medical help eight billion times in 2016, a number that is equivalent to the world’s population, according to Mr. Mao. There were roughly 50,000 medical-related disputes in that period, a tiny fraction of the total number of health visits.

“Therefore, our judgment is the doctor-patient relationship in reality isn’t tense,” Mr. Mao said.

On the Front Line

If Beijing hopes to overhaul health care, it needs to persuade a skeptical public to stop going to the hospital for the sniffles.

To help change the culture, China is pushing each household to sign a contract with a family doctor by 2020 and subsidizing patients’ visits. General practitioners will also have the authority to make appointments directly with top specialists, rather than leaving patients to make their own at hospitals.

Such measures would make it easier for patients to transfer to top hospitals without a wait, while potentially giving them more personalized care from a doctor who knows their history. It could also cut down on costs, since it is cheaper under government insurance to see a family doctor.

Image

Dr. Zhu Min, who practices family medicine in Shanghai, splits her time between the local clinic, a hospital and patients’ homes.CreditGilles Sabrié for The New York Times

After the government’s directive, Dr. Yang Lan has signed up more than 200 patients, and monitors their health for about $1,220 a month. From her office in the Xinhua community health center, a run-down place with elderly patients milling about in the corridors, she keeps track of her patients with an Excel sheet on her computer. She said she had memorized their medical history and addresses.

Dr. Yang, 31, said her practice was largely free of grumpy patients and, as a result, “yi nao.” She sees 50 to 60 patients in a workday of about seven and a half hours. In the United States, a family doctor has 83 “patient encounters” in a 45-hour workweek, according to a 2017 survey by the American Academy of Family Physicians. That’s about 16 patients in a nine-hour workday.

The patients get something, too — a doctor who has time for them. Every three months, Dr. Yang has a face-to-face meeting with her patients, either during a house call or at her clinic. She’s available to dispense round-the-clock advice to her patients on WeChat, a popular messaging app in China. A patient is generally kept in the waiting room for a brief period and, if necessary, gets to talk with her for at least 15 minutes.

On a hot summer day, an elderly woman with white hair walked into Dr. Yang’s clinic. She has cardiovascular disease, and Dr. Yang told her to watch what she ate. Next, a man with diabetes dropped in. “Hey, you got a haircut!” Dr. Yang exclaimed. At one point, four retirees swarmed Dr. Yang’s room, talking over one another.

“I think she’s really warm and considerate,” said Cai Zhenghua, the patient with diabetes. He used to seek treatment at a hospital, he said, adding, “The time spent interacting with doctors here is much longer.”

The government aims to increase the number of general practitioners to two or three, and eventually five, for every 10,000 people, from 1.5 now. But to even have a chance of reaching its goals, China needs to train thousands of doctors who have no inkling of how a primary care system should function and little interest in leaving their cushy jobs in the public hospitals.

It is forcing hospital specialists to staff the community clinics every week and paying those doctors subsidies to do so. It is also trying to improve the bedside manner of doctors with government-backed training programs.

Image

Patients waiting for lab results at the Weifang clinic.CreditGilles Sabrié for The New York Times

In Shanghai, Du Zhaohui, then the head of the Weifang community health service center, introduced a test that uses mock patients to evaluate the care and skills of general practitioners. The doctors have 15 minutes to examine “patients.” The teachers use a checklist to grade the doctors on things like making “appropriate eye contact” and “responding appropriately to a patient’s emotions.”

At a recent test, one doctor, wearing crystal-studded Birkenstock sandals, examined a patient who had insufficient blood flow to the brain by swinging a tiny silver hammer, the equipment that is used for testing reflexes.

“That isn’t the right way,” Li Yaling, head of the center’s science and education department, said with a sigh. She said the doctor was probably too nervous and should have used a cotton swab to stroke the soles of the patient’s feet instead.

Dr. Zhu Shanzhu, a teacher in the program, said one of the main problems was that doctors did too few physical examinations in the community clinics. Many of them lean toward prescribing medicine instead. Clinical reasoning, too, is poor, she said.

In 2000, Dr. Zhu designed a course to train general practitioners in Shanghai’s Zhongshan Hospital, at the request of its director. Her first course was free. No one showed up.

Nearly two decades later, Dr. Zhu, 71, says that training is still insufficient and doctors do not spend enough time studying the latest research and techniques in their field.

“If there’s more money, the good people will come,” she said. “And a high economic status will elevate the social status.”

The government has pledged to increase the salaries of family doctors. But Dr. Zhu isn’t optimistic.

“All these ministries need to coordinate among themselves,” she said. “Our country’s affairs, you know, they aren’t easy.”

Follow Sui-Lee Wee on Twitter: @suilee.

Research was contributed by Zhang Tiantian, Zoe Mou, Qi Xu, Tang Yucheng, Amy Cheng and Elsie Chen.

A version of this article appears in print on

, on Page

A

1

of the New York edition

with the headline:

Lines, Bribes and Violence: A Health Care Crisis

. Order Reprints | Today’s Paper | Subscribe

Read More | https://www.nytimes.com/2018/09/30/business/china-health-care-doctors.html |

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’, in 2018-10-01 14:49:05

[algarithmblognumber]

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’ http://www.nature-business.com/nature-chinas-health-care-crisis-lines-before-dawn-violence-and-no-trust/

Nature

Video

Homemade cancer drugs, violence in hospitals, doctor shortages: We take you inside China’s broken health care system to reveal how dire the situation is for over a billion people.Published OnSept. 30, 2018CreditCreditImage by Gilles Sabrié for The New York Times

BEIJING — Well before dawn, nearly a hundred people stood in line outside one of the capital’s top hospitals.

They were hoping to get an appointment with a specialist, a chance for access to the best health care in the country. Scalpers hawked medical visits for a fee, ignoring repeated crackdowns by the government.

A Beijing resident in line was trying to get his father in to see a neurologist. A senior lawmaker from Liaoning, a northeastern province, needed a second opinion on her daughter’s blood disorder.

Mao Ning, who was helping her friend get an appointment with a dermatologist, arrived at 4 a.m. She was in the middle of the line.

“There’s no choice — everyone comes to Beijing,” Ms. Mao, 40, said. “I think this is an unscientific approach and is not in keeping with our national conditions. We shouldn’t have people do this, right? There should be a reasonable system.”

The long lines, a standard feature of hospital visits in China, are a symptom of a health care system in crisis.

Image

Dr. Ye Minghao, a family practitioner in Shanghai, sees up to 80 patients a day. He enjoys his work, he said, but is unhappy about the lack of respect for his field.CreditGilles Sabrié for The New York Times

An economic boom over the past three decades has transformed China from a poor farming nation to the world’s second-largest economy. The cradle-to-grave system of socialized medicine has improved life expectancy and lowered maternal mortality rates.

But the system cannot adequately support China’s population of more than one billion people. The major gaps and inequalities threaten to undermine China’s progress, social stability and financial health — creating a serious challenge for President Xi Jinping and the Communist Party.

Then, there are the scandals. In July, hundreds of thousands of children were found to have been injected with faulty vaccines. The news angered the public, rattling confidence in the government and amplifying frustration with the health care system.

While the wealthy have access to the best care in top hospitals with foreign doctors, most people are relegated to overcrowded hospitals. In the countryside, people must rely on village clinics, or travel hundreds of miles to find the closest facility.

The country does not have a functioning primary care system, the first line of defense for illness and injury. China has one general practitioner for every 6,666 people, compared with the international standard of one for every 1,500 to 2,000 people, according to the World Health Organization.

Instead of going to a doctor’s office or a community clinic, people rush to the hospitals to see specialists, even for fevers and headaches. This winter, flu-stricken patients camped out overnight with blankets in the corridors of several Beijing hospitals, according to state media.

Hospitals are understaffed and overwhelmed. Specialists are overworked, seeing as many as 200 patients a day.

Image

Nurses reviewing the patient list at the Gaoqiao community health service center in Shanghai. Hoping to get more people to use local clinics instead of hospitals, the government is paying specialists subsidies to staff them.CreditGilles Sabrié for The New York Times

And people are frustrated, with some resorting to violence. In China, attacks on doctors are so common that they have a name: “yi nao,” or “medical disturbance.”

In 2016, Mr. Xi unveiled the country’s first long-term blueprint to improve health care since the nation’s founding in 1949. Called Healthy China 2030, it pledged to bolster health innovation and make access to medical care more equal.

The deficiency in doctors has taken on more urgency as the Chinese government grapples with the mounting health problems of its vast population. Heart disease, strokes, diabetes and chronic lung disease account for 80 percent of deaths in China, according to a World Bank report in 2011.

Mao Qun’an, the spokesman for the National Health and Family Planning Commission, acknowledged that the hospitals could no longer meet the public’s needs.

“If you don’t get the grass roots right, then the medical problems in China cannot be solved,” Mr. Mao said. “So what we’re doing now is trying to return to the normal state.”

A Lack of Respect

On some mornings, Dr. Huang Dazhi, a general practitioner in Shanghai, rides his motorbike to a nursing home, where he treats about 40 patients a week. During lunchtime, he sprints back to his clinic to stock up on their medication and then heads back to the nursing home.

Afterward, he makes house calls to three or four people. On other days, he goes to his clinic, where he sees about 70 patients. At night, he doles out advice about high-blood-pressure medications and colds to his patients, who call him on his mobile phone.

Image

Dr. Huang Dazhi, a general practitioner in Shanghai, is paid about $1,340 a month — roughly his starting pay as a specialist 12 years ago.CreditGilles Sabrié for The New York Times

For all this, Dr. Huang is paid about $1,340 a month — roughly the same he was making starting out as a specialist in internal medicine 12 years ago.

“The social status of a general practitioner is not high enough,” Dr. Huang said, wearing a gray Nike T-shirt and jeans under his doctor’s coat. “It feels like there’s still a large gap when you compare us to specialists.”

In a country where pay is equated with respect, the public views family doctors as having a lower status and weaker credentials than specialists. Among nearly 18,000 doctors, only one-third thought that they were respected by the public, according to a 2017 survey by the Chinese Academy of Medical Sciences, Peking Union Medical College, Brigham and Women’s Hospital in Boston, Harvard Medical School, the Harvard T.H. Chan School of Public Health and the U.S. China Health Summit.

“There is no trust in the primary care system among the population because the good doctors don’t go there,” said Bernhard Schwartländer, a senior aide at the World Health Organization and its former representative to China. “They cannot make money.”

China once had a broad, if somewhat basic, primary health care system. “Barefoot doctors” roamed the countryside treating minor ailments. In the cities, people got their health care at clinics run by state-owned companies.

China’s “barefoot doctor” system was one of the Communist revolution’s most notable successes. In 1965, Chairman Mao, troubled by the lack of health care in the countryside, envisioned an army of people who spent half their time farming (many worked in the fields without shoes) and half their time treating patients. They weren’t doctors, but rather a sort of health care SWAT team. The authorities gave them a short training period — several months to a year — and a bag of limited medicine and equipment.

Average life expectancy in China increased to 63 years in 1970 from 44 in 1960, according to Theodore H. Tulchinsky and Elena A. Varavikova, authors of “The New Public Health,” a book about global medical care. The maternal mortality rate in rural China fell to 41.3 per 100,000 people from 150 per 100,000 before 1949, according to a 2008 article published by the World Health Organization. In the same period, the infant mortality rate fell to 18.6 per 1,000 from 200.

Image

A training session for family doctors at the Weifang community health service center in Shanghai.CreditGilles Sabrié for The New York Times

But the public was fed up that it could not get medical treatment whenever or wherever it wanted. People needed a referral to see a specialist in a hospital.

In the mid-1980s, the government lifted the barriers, allowing people to be treated in hospitals. At the same time, China began an economic overhaul that led to the dismantling of the entire system. Government subsidies were cut drastically, and hospitals had to come up with ways to generate profits.

As hospitals started investing in high-tech machines and expanded to meet their new financial needs, medical students were drawn to them. Many believed that being a specialist would guarantee them an “iron rice bowl,” a job that was secure with an extensive safety net that included housing and a pension.

Dr. Huang initially followed the more lucrative path. After graduating from medical school in 2006, he started working as an internist in a hospital in Shanghai.

But he kept seeing patients with simple aftercare needs like removing stitches, changing catheters and switching medication. “These things really should not be done by us specialists,” he said.

When Dr. Huang saw a newspaper article about general practitioners, he decided to enroll in a training program in 2007. He was inspired by his aunt, a “barefoot doctor” in Mingguang, a city in Anhui Province, one of the poorest regions in China.

As a boy, he had followed his aunt as she went to people’s homes to deliver babies and give injections. “After becoming a doctor, I’ve realized that the people’s needs for ‘barefoot doctors’ is still very much in demand,” he said.

Image

An electronic board at the entrance of Peking Union Hospital displays the number of doctors available and their specialty.CreditGilles Sabrié for The New York Times

Corruption and Backlash

In March, a doctor was killed by his patient’s husband. In November 2016, a man attacked a doctor after an argument over his daughter’s treatment. The month before, a father stabbed a pediatrician 15 times after his daughter died shortly after her birth. The doctor did not survive.

Dr. Zhao Lizhong, an emergency room doctor in Beijing, was sitting at a computer and writing a patient’s diagnosis when Lu Fu’ke plunged a knife into his neck in April 2012. Around him, patients screamed.

Hours earlier, Mr. Lu had stabbed Dr. Xing Zhimin, who had treated him for rhinitis, in the Peking University People’s Hospital and fled. Police officers arrested him in his hometown, Zhuozhou in the northern province of Hebei, later that month. Mr. Lu was sentenced to 13 years in jail.

“We know that this kind of thing can happen at any time,” Dr. Zhao said.

The root of the violence is all the same: a mistrust of the medical system.

It goes back to the market reforms under Deng Xiaoping in the 1980s. After the government cut back subsidies to hospitals, doctors were forced to find ways to make money. Many accepted kickbacks from drug companies and gifts from patients.

In a survey of more than 570 residents in Beijing, Shanghai and Guangzhou conducted in 2013 by Cheris Chan, a sociology professor at the University of Hong Kong, more than half said they and members of their family gave “red envelopes” as cash gifts to doctors for surgery during 2000-12.

Dr. Yu Ying, who worked as an emergency room doctor at Peking Union Hospital, one of China’s top hospitals, said she was once a valiant defender of her profession. On her widely followed account on Weibo, China’s version of Twitter, she pushed back against critics who called doctors “white-eyed wolves.”

Image

Dr. Yu Ying, who worked in Peking Union Hospital’s emergency room, said she had heard accounts of doctors who accepted thousands of dollars in kickbacks.CreditGilles Sabrié for The New York Times

“After I discovered the truth, I really had to give myself a slap in the face,” she said.

Dr. Yu said she had heard accounts from outpatient doctors who accepted thousands of dollars in kickbacks from drug companies — “cash that was bundled into plastic bags.”

“In the entire system, the majority of doctors accept red envelopes and kickbacks,” she said.

The corruption is endemic. GlaxoSmithKline paid a $500 million fine in 2014, the highest ever in China at the time, for giving kickbacks to doctors and hospitals that prescribed its medicines. Eli Lilly, Pfizer and other global drug giants have settled with regulators over similar behavior.

It all makes for a violent mix.

Many hospitals are taking measures to protect their workers. In the southern city of Guangzhou, the Zhongshan Hospital has hired taekwondo experts to teach doctors self-defense techniques. Hospitals in the eastern city of Jinan are paying private security companies for protection. Last year, the government pledged to station an adequate number of police officers in emergency departments, where most doctor-patient violence occurs.

Mr. Mao, the spokesman for the health ministry, said that while the figures for attacks on medical personnel looked alarming, they needed to be put in context. Chinese patients sought medical help eight billion times in 2016, a number that is equivalent to the world’s population, according to Mr. Mao. There were roughly 50,000 medical-related disputes in that period, a tiny fraction of the total number of health visits.

“Therefore, our judgment is the doctor-patient relationship in reality isn’t tense,” Mr. Mao said.

On the Front Line

If Beijing hopes to overhaul health care, it needs to persuade a skeptical public to stop going to the hospital for the sniffles.

To help change the culture, China is pushing each household to sign a contract with a family doctor by 2020 and subsidizing patients’ visits. General practitioners will also have the authority to make appointments directly with top specialists, rather than leaving patients to make their own at hospitals.

Such measures would make it easier for patients to transfer to top hospitals without a wait, while potentially giving them more personalized care from a doctor who knows their history. It could also cut down on costs, since it is cheaper under government insurance to see a family doctor.

Image

Dr. Zhu Min, who practices family medicine in Shanghai, splits her time between the local clinic, a hospital and patients’ homes.CreditGilles Sabrié for The New York Times

After the government’s directive, Dr. Yang Lan has signed up more than 200 patients, and monitors their health for about $1,220 a month. From her office in the Xinhua community health center, a run-down place with elderly patients milling about in the corridors, she keeps track of her patients with an Excel sheet on her computer. She said she had memorized their medical history and addresses.

Dr. Yang, 31, said her practice was largely free of grumpy patients and, as a result, “yi nao.” She sees 50 to 60 patients in a workday of about seven and a half hours. In the United States, a family doctor has 83 “patient encounters” in a 45-hour workweek, according to a 2017 survey by the American Academy of Family Physicians. That’s about 16 patients in a nine-hour workday.

The patients get something, too — a doctor who has time for them. Every three months, Dr. Yang has a face-to-face meeting with her patients, either during a house call or at her clinic. She’s available to dispense round-the-clock advice to her patients on WeChat, a popular messaging app in China. A patient is generally kept in the waiting room for a brief period and, if necessary, gets to talk with her for at least 15 minutes.

On a hot summer day, an elderly woman with white hair walked into Dr. Yang’s clinic. She has cardiovascular disease, and Dr. Yang told her to watch what she ate. Next, a man with diabetes dropped in. “Hey, you got a haircut!” Dr. Yang exclaimed. At one point, four retirees swarmed Dr. Yang’s room, talking over one another.

“I think she’s really warm and considerate,” said Cai Zhenghua, the patient with diabetes. He used to seek treatment at a hospital, he said, adding, “The time spent interacting with doctors here is much longer.”

The government aims to increase the number of general practitioners to two or three, and eventually five, for every 10,000 people, from 1.5 now. But to even have a chance of reaching its goals, China needs to train thousands of doctors who have no inkling of how a primary care system should function and little interest in leaving their cushy jobs in the public hospitals.

It is forcing hospital specialists to staff the community clinics every week and paying those doctors subsidies to do so. It is also trying to improve the bedside manner of doctors with government-backed training programs.

Image

Patients waiting for lab results at the Weifang clinic.CreditGilles Sabrié for The New York Times

In Shanghai, Du Zhaohui, then the head of the Weifang community health service center, introduced a test that uses mock patients to evaluate the care and skills of general practitioners. The doctors have 15 minutes to examine “patients.” The teachers use a checklist to grade the doctors on things like making “appropriate eye contact” and “responding appropriately to a patient’s emotions.”

At a recent test, one doctor, wearing crystal-studded Birkenstock sandals, examined a patient who had insufficient blood flow to the brain by swinging a tiny silver hammer, the equipment that is used for testing reflexes.

“That isn’t the right way,” Li Yaling, head of the center’s science and education department, said with a sigh. She said the doctor was probably too nervous and should have used a cotton swab to stroke the soles of the patient’s feet instead.

Dr. Zhu Shanzhu, a teacher in the program, said one of the main problems was that doctors did too few physical examinations in the community clinics. Many of them lean toward prescribing medicine instead. Clinical reasoning, too, is poor, she said.

In 2000, Dr. Zhu designed a course to train general practitioners in Shanghai’s Zhongshan Hospital, at the request of its director. Her first course was free. No one showed up.

Nearly two decades later, Dr. Zhu, 71, says that training is still insufficient and doctors do not spend enough time studying the latest research and techniques in their field.

“If there’s more money, the good people will come,” she said. “And a high economic status will elevate the social status.”

The government has pledged to increase the salaries of family doctors. But Dr. Zhu isn’t optimistic.

“All these ministries need to coordinate among themselves,” she said. “Our country’s affairs, you know, they aren’t easy.”

Follow Sui-Lee Wee on Twitter: @suilee.

Research was contributed by Zhang Tiantian, Zoe Mou, Qi Xu, Tang Yucheng, Amy Cheng and Elsie Chen.

A version of this article appears in print on

, on Page

A

1

of the New York edition

with the headline:

Lines, Bribes and Violence: A Health Care Crisis

. Order Reprints | Today’s Paper | Subscribe

Read More | https://www.nytimes.com/2018/09/30/business/china-health-care-doctors.html |

Nature China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’, in 2018-10-01 14:49:05

[dawnajaynes32]

Catching Up with 10 Design Leaders from the ’90s & Early 2000s

Let’s revisit 10 of the people who played major roles in the design industry in the ’90s and early 2000s: David Carson, Bill Cahan, Sean Adams, Noreen Morioka, Robynne Raye, Michael Strassburger, John Sayles, Sheree Clark, David Salanitro and Jennifer Sterling

Some are still doing the work they’ve always loved. Others have changed careers completely. But all of them are applying the same creative passion that elevated their design work decades ago to their new pursuits.

In the early ’90s, the graphic design landscape was undergoing a dramatic shift. Desktop publishing was in its infancy and everyone was making it up as they went along—some better than others—while trying to keep up with the new technology and software. Then in 2000, the dotcom bubble burst, and in 2008 the worst recession since the Great Depression hit. Many studios weathered the storm, while others simply closed shop.

Here, we talk with the survivors of the past few decades, many of whom have reimagined their careers, and in some cases, started new vocations altogether.

Where Are They Now? Catching Up with 10 Design Leaders from the ’90s & Early 2000s

Cahan & Associates: 2001 Gartner Annual Report.

Cahan & Associates, 1984–2009

Bill Cahan San Francisco

Remember when “annual reports” was the behemoth category in every design competition? No? Well, we do, and Cahan & Associates always earned top honors and swept the category. Bill Cahan and his designers changed the game when it came to designing the dreaded annual report. But, in 2009, Cahan closed shop after a near-death illness. As he says, “After 25 years of working like a maniac, I saw the illness and the economy crashing as a sign from the universe to change my life. I let go of everyone in my company and gave all the work we had to two associates, who started their own firm, with the caveat that they rehire everyone.”

He took a year off to reassess his life and get healthy, and in the process ended up meeting his future wife, and eventually having a son with her in 2011. Cahan also co-founded a nonprofit called NARPP, to help advocate for individual savers by creating a universal savings plan to help people get access to a 401(k) plan.

“The changes over the last 20 years have inspired me to shift my priorities. It started with a thought of ‘how can we harness the power of design to solve big social challenges that can impact people’s lives in meaningful ways?’ And that lead to me working with an interdisciplinary team of experts in communication theory, behavioral finance and choice architecture who collectively have a deep understanding of the behavioral and cognitive barriers to people making decisions in their best interests,” he explains. “I have seen the impact of this kind of work, and believe this shift could be a requirement for more effective design in the 21st century.”

He adds, “On a personal note, when I am not working, I am with my family. Being a stay-at-home dad and husband has been humbling and challenging in the best of ways: I am learning to listen more and talk less.”

AdamsMorioka: Nickelodeon branding manual.

AdamsMorioka, 1994–2014

Sean Adams, Noreen Morioka Los Angeles

“In 1994, when we started AdamsMorioka, our goal was to clean up the world, make design accessible and focus on optimism,” notes Sean Adams. And they did. Their work for Sundance, Nickelodeon and Disney, to name a few, was bold and bright in a time when much of the design was going dark and goth. The duo was covered extensively in trade publications, they were traveling and speaking about their work—and winning lots of design awards.

They were not only busy running their own successful agency, but also selflessly supporting and serving their professions, with Adams serving more than two terms as the National AIGA president, and Morioka as AIGA Los Angeles president. Adams had also started teaching design at ArtCenter, and he fell in love with it. But it was too much of a good thing and something had to give. Late in 2014, Adams and Morioka went their separate ways.

Adams is now executive director of the Graphic Design Graduate Program at ArtCenter, and he teaches online courses for Lynda.com/LinkedInLearning. Design education is his passion, and he sees so much potential in design thinking and how it can change the world. “I want designers to be the people in the room who see the big picture and challenge the status quo, not merely the person who can make a pretty logo. A software program or new technology can’t replace smart thinking and real innovation,” Adams notes. He also runs his studio, Burning Settlers Cabin, and has written several books.

AdamsMorioka: 2004 Sundance Film Festival poster.

Morioka became a partner and creative strategist with her wife, Nicole Jacek at NJ(L.A.). But she has a very different perspective than when she was at AdamsMorioka. “There is a very obvious sexist perception about a women-owned company from clients and peers,” Morioka notes. “Nicole and I were surprised that most potential clients would expect a male team member to handle the financial and contract needs. Even more alarming was the perception that women creatives could only handle ‘boutique’ projects.” As a veteran designer, she had hoped that the industry had moved past this. “Not only do we need to be aware that our profession does this, but we need to stop pretending that it will eventually go away. Better yet, we need to give more opportunities to women so their successes can evolve and eliminate this sexist perception,” she says.

  They recently left Los Angeles, and moved to Portland, Ore., to lead the design studio at Wieden+Kennedy. “Nicole and I never thought in a million years that we would leave the warm weather of L.A., but W+K team have their own unique way of turning up the heat with their talent and thinking.”

David Carson: Ray Gun magazine cover.

David Carson

Art Director, Ray Gun magazine 1992–1995 Manhattan Beach, CA

David Carson became the poster boy for breaking the rules in graphic design for his misappropriation of type and images as art director of Ray Gun magazine in the early ’90s. People either loved or hated it, which was just fine with Carson. He did what he wanted and picked up many design awards along the way. In 2014, he was awarded the AIGA Medal for his unique design signature and his influence on the next generation of designers. Carson is still doing design his way and staying close to the beach so he can surf when the tide is right.

David Carson: Starboard surfboard graphics.

Much of his work of late reflects his passion and respect for the ocean and its wildlife. He recently created posters for Kill the Fin Trade, whose mission is to ban the shark fin trade in Australia, and he’s designing a line of surfboards for Starboard. The trademark Carson influence is evident in his designs. You can see the thought process and deliberation in his work, and it’s something he doesn’t take for granted, although he thinks a lot of designers aren’t using their heads enough. “There’s a gentrification of design,” he says. “Software and computers continue to make designers lazy, letting the computer make decisions for them. This will only get worse as large-scale projects are in beta testing right now that will eliminate a lot of current design jobs.”

Jennifer Sterling: 2001 AIGA 365 Annual.

Jennifer Sterling

Jennifer Sterling has worked on both coasts, designing for clients in a variety of industries including fashion, editorial, luxury goods and high-tech. She is known for weaving textural images and typography in interesting ways to create depth and discourse. Unfortunately, many thought she took it too far in the 2001 AIGA 365 Annual, and she experienced a profound backlash from her peers for the way she portrayed the images. “I cropped the images to show why a piece was lovely. All annuals had been, to this point, a cover and a spread, which really showed you nothing,” she explains. “I wanted the end reader to see the remarkable use of tactile devices, if that was what was prevalent, or the lovely calligraphy, or the juxtaposition of photography. It was all to honor these designers, many of whom were my heroes.” Needless to say, she wasn’t prepared for the reaction she received. Today, this design would be praised for its ingenuity.

Jennifer Sterling: Experimenting with AI imagery.

Since then, she has worked on many life-changing campaigns including branding for “Vital Voices,” a non-governmental organization to promote female ambassadorships founded by Hillary Clinton and Madeline Albright, and an online interactive piece for Yahoo to deliver the AIDs vaccine to third-world countries. Currently, Sterling is based in New York City, still experimenting with typography and seeing how far she can push it using technology. “While my firm has spanned two decades I have witnessed a great deal. The Internet eliminated a major constraint to accessing and sharing knowledge. Because it is in the hands of 3 billion people worldwide in the form of portable devices, it has also eliminated the need for a central or permanent location for creating and organizing information. This and the staggering advances in media compression has made innovation in all fields (not just design) quicker and easier to build on,” she says. “As far as challenges for the future the design arena has ultimately been responsible for one of two things: The product or the message. As AI (artificial intelligence) and VR (virtual reality) become more commonplace in society the questions and responsibilities of how and why will become more necessary, both as a consumer and as an innovator or citizen.”

Sayles Design: Jim Beam package design, early 1990s.

Sayles Graphic Design 1985–2009

J. Sayles Design, 2009–present John Sayles and Sheree Clark Des Moines, Iowa

This Midwest firm grew fast and steady in the ’80s and ’90s. John Sayles had the creative chops, and Sheree Clark ran the business side, wrangling new clients and nurturing those relationships. As a team, they were unstoppable … until the economy crashed in 2008. “We found our clients downsizing. The contacts we had established over the years were being let go. It became apparent we had to re-establish our approach and our connections,” Sayles explains. “Sheree and I had to face that the business could no longer support the overhead of the business, which included seven employees.” They closed SGD. Clark shifted gears to pursue her new passion, which revolved around nutrition and healthy eating. Sayles took time to “breathe and reset” before starting over as a one-man shop, J. Sayles Design. 

Sayles Design: Swell packaging.

In addition to his agency, in 2015 Sayles started a vodka company called Swell. It’s now the second fastest growing Iowa Spirits company, due in large part to his branding expertise. “This is what I have been doing for more than 25 years,” he says. “I know how to market and promote a product without spending millions of dollars.”

Sayles Design: Sheree Clark at work doing a food prep demonstration for a local television program.

Clark’s journey is quite different. She’s gone from running a design business to helping people design better lives for themselves. “Fork in the Road [her business] is truly a crescendo of all my life experiences. I work with clients to problem-solve, and ultimately to transform their health, reclaim vitality and mental focus, and help ensure they gain clarity on their vision and purpose. These are all things I have done for myself over the course of the last six-plus decades of life.”

David Salanitro: 2001 AIGA San Francisco Paper Show promotion.

Oh Boy, 1994–2001

Oh Boy Artifacts, 2001–present David Salanitro San Francisco

Oh Boy, founded by David Salanitro, was one of the hottest agencies in the late ’90s, producing elegant corporate communications and branding materials for companies like Mohawk Paper, Schwab and West Coast Industries. In 2001, Salanitro launched Oh Boy Artifacts, a beautiful collection of high-end notebooks, journals, giftwrap and other fine paper products. These coveted items were an instant hit, and designers couldn’t wait to get their hands on them. But, just as quickly as the Artifacts collection came on the scene, the agency was struggling.

“Nearing the end of 2001, the recession came upon us, and the studio quite suddenly shed its clients,” Salanitro says. Artifacts carried the studio for a while, but it wasn’t enough, so he closed shop and moved to the east coast to continue the Artifacts collection.

David Salanitro: Corporate literature for Orgel Wealth Management.

He took some time off to reflect, read and write. In the ensuing years, he returned to the west coast and lectured at the Academy of Art University, then he moved to Chicago to work for Avenue as the executive creative director, and then ended up in his hometown, Fresno, CA, where he currently resides. Lucky for us, he’s launching a new Artifacts collection this year through Kickstarter.

“This time I see it differently, I see that it can be important,” he says. “There is a certain beauty evident in a thing by the measure of care people invest in it. It’s a simple if/then equation: If we care enough about what we make, if we go all in and put the whole of our capacity into it and consider it in a larger context—the way something catches the light, the grain of its surface—then others too will pause and take notice. The consideration I give to a simple thing like a notebook, or our part in grander gestures that inspire people to forgo the paper sack and return to wrapping gifts, is evidence of that care that we pass along. I don’t want to sell paper. I want to bring back the sense of event to gift giving and encourage people to pause and grin and share a few extra moments of appreciation—of one another. … The ground is shifting. More people are trying to take better care. We are trying to craft our lives in ways that allow us to recognize beauty and smile. I’m in this for the grins.”

Michael Strassburger: Stinky Teenager packaging.

Modern Dog 1987–present

Robynne Raye & Michael Strassburger Seattle

Every designer in the ’90s envied Modern Dog, led by Robynne Raye and Michael Strassburger. They designed posters for local theater companies and musicians such as Liz Phair, The Pretenders, Better than Ezra and The Roots, among others. They made it look so cool and easy. “I think at one time—in the ’90s—we were working for five different theaters in Seattle,” Raye recalls. “There’s a very small percentage of people that go to live theater, and it was weird for us, because we were trying to get the same people to the different theaters. We were essentially competing against ourselves in this genre, and we wondered why they didn’t just hire other designers. That was very strange.”

Things sailed smoothly through the early 2000s, as well. In fact, in 2007, the Louvre requested five Modern Dog posters for its permanent art collection. Raye and Strassburger couldn’t believe it! Then in 2011, everything changed. One of their designs was ripped off and repurposed on Disney merchandise sold at Target. The two decided to sue the big corporations for copyright infringement—perhaps against their better judgment. To pay their attorneys, they sold the Modern Dog building, let go of the few employees they had, and moved the business into Raye’s basement. Although they eventually won their case, it took three years and nearly bankrupted them. Modern Dog is now a part-time venture, with its principals taking on new roles.

Modern Dog: Flaming Lips poster.

“I do about 8-12 projects a year,” Raye says. “Currently, I’m rebranding a small hair salon, designing a poster and conducting a workshop at Amazon. I divide my time between teaching at two Seattle Colleges—Cornish College of the Arts and Seattle Central College—and doing design work through Modern Dog.”

Since 2012, Strassburger has worked full time at the Seattle Aquarium. He is still technically vice president of Modern Dog, though he is not involved in the day-to-day activities. He also has a new company called Living Fancy. “I’m not the young buck I used to be, and after decades as co-founder of Modern Dog helping design products for clients like Blue Q, I needed to settle things down a bit,” he explains. “The most natural evolution for me was to start my own line of products as Living Fancy. Now I am my own product developer, art director and designer! I can’t help it. I just love doing this stuff.”

Robynne Raye: Walla Walla poster design.

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