Wake up（228）

 

228

 

When human beings are in eternal conflict with reason, emotion has never lost their hand. True feelings come from mutual recognition in the heart. The first meeting between old Chinese medicine practitioner Chai Jianhua and Bai Bingqing, Liu Hanyu, and Qu Ting was to discuss China’s medical system reform endlessly, because they are all practitioners, and the duty of doctors is to save lives and heal the wounded, so how to make the people feel better when they are sick? Getting rid of pain and gaining a new life in suffering is an endless topic.

When Bai Bingqing and Liu Hanyu talked about these things, they did not discuss the cures or diagnosis and treatment techniques encountered in medical treatment. They were more concerned about the national medical system. According to Bai Bingqing, to solve the medical problems of the people, we must prescribe the right medicine. The root cause of the disease lies in the corruption and imperfection of the medical system.

Liu Hanyu believes that the focus of the inland medical system is that the rulers regard people's livelihood as nothing. The three-year rampage of the new crown virus is actually a test of the changes in people's livelihood awareness and a test of the government's prevention and control capabilities. Too many lies have been deceiving the people, but sometimes the untrue contains more truth than the true. Because, when the people wake up, the people's patience will reach its limit.

Veteran Chinese doctor Chai Jianhua has never discussed the inland medical system with anyone in China. He dared not talk about it, and no one talked to him about these sensitive matters. He did not expect that the first conversation he had with his new friend after he arrived in Hong Kong would open his eyes.

At this moment, female nurse Qu Ting interjected. She said to Chai Jianhua: My mother used to work as a barefoot doctor in the inland. Gradually, she gradually lost a lot of knowledge that was too heavy in the brainwashing, and filled it with new knowledge from Hong Kong and the West. She is most concerned about the marketization of public health care in Taiwan. She studied medicine in Taiwan, and she often talked to me about the marketization of public health care in Taiwan.

Qu Ting said: Under the arrangement of my mother, I also went to Taiwan for medical training when I was young. Let me first describe the historical background of Taiwan's marketization.

After the recovery of Taiwan after World War II, the Kuomintang withdrew to Taiwan in 1949. At that time in mainland China, the Kuomintang actually stood with the landlords and financial groups. In contrast, the CCP was of course completely different. The CCP stood with the peasants and workers. Under such circumstances, the Kuomintang gradually lost the support of the mainland people, was defeated in the civil war between the Kuomintang and the Communist Party, and had to retreat to Taiwan. This was a very painful lesson for the Kuomintang. So after the Kuomintang came to Taiwan, it understood that Taiwan was the only place it could inhabit. So, after the Kuomintang arrived in Taiwan, it quickly promoted the land reform. During the period in mainland China, the Kuomintang could not promote the land reform because it stood with the landlords, but it was easier in Taiwan because it had not yet cooperated with Taiwan. The local landlords and consortiums established a cooperative relationship, and because the Kuomintang held absolute power and resources at that time, the Taiwanese landlords had to make concessions. At the same time, the Kuomintang promoted the policies of import substitution and equalization of land rights—this was a slightly socialist-oriented people’s livelihood policy in Sun Yat-sen’s Three Principles of the People. Restraining private capital and capital from developed countries were the main policy guidelines at that time. This is about a decade or two since the Kuomintang established its regime in Taiwan.

But in the 1960s, 1970s, and until the 1980s, it reversed, and one of the big driving forces behind it was the United States. At that time, the socialist camp performed very well in the economy. For the United States, the leader of the capitalist social camp, it was not very happy to see it. It was worried that the good performance of the socialist camp would have a negative impact on the capitalist camp. Therefore, they envy socialism and hope that their society will also implement socialism. That's why the United States promoted the four Asian tigers at that time, including Taiwan, South Korea, Singapore and Hong Kong, and promoted the export-oriented economic policies of these four regions. , against the socialist camp.

Interestingly, the mainland also tried its best to publicize the experience of the four Asian tigers. The mainland has implemented an export-oriented policy, and its economic policy has gradually shifted from controlling private capital and the capital of developed countries to a policy of encouraging the expansion and accumulation of private capital and reducing national capital.

Qu Ting said: I went to Taiwan to study medicine in the mid-1980s. Corresponding to the international situation at that time, in Taiwan it was the rise of "neo-liberalism", deregulation, and privatization. In Taiwan, there was another word called "organizational reengineering", which was market-oriented reform: weight loss, layoffs, more and more more market-oriented. From the 1960s to today, Taiwan's marketization is a historical development process.

Under such a market-oriented economic development, Taiwan’s public health policy from the 1950s, 1960s, and mid-1970s focused on prevention over treatment. building. This policy clearly began to reverse in the late 1970s and 1980s. With the reversal of this economic and public health policy, the public health system began to be medicalized—the so-called "medicalization of the public health system" means that in the two major departments of the public health system, the prevention and medical treatment, the medical department has no financial or human resources. Accounted for the vast majority of the proportion, while the prevention sector is relatively very low proportion. During this period, the government and private capital began to invest heavily in the medical sector, and the government also began to encourage private capital to invest in the medical field. Coupled with the law that private capital will continue to expand and accumulate, the medical sector will continue to expand. Relatively, the government’s investment in the prevention sector is weak, and it has not responded to the shift in the form of disease among Taiwanese people from infectious diseases to Changes dominated by chronic diseases have increased. Not only has this change occurred in Taiwan, but the mainland has also experienced this change.

Qu Ting continued: Let’s analyze the difference in commercialization between the medical department and the prevention department. I think the medical services provided by medical institutions are relatively easy to convert into commodities, because most of the medical services are personal, that is, they can be standardized and quantified for individual needs or needs, so the services provided by the medical sector are relatively It is easy to be commercialized, and after commercialization, it will be marketized. On the contrary, the services provided by the prevention department, such as environmental sanitation and prevention and control of infectious diseases, are not personal but public. For example, the work of environmental sanitation is for the collective rather than the individual, and most of them are not easy to standardize or Quantification, so most preventive services cannot be converted into commodities, cannot be bought and sold, and therefore cannot be exchanged for equivalent value in currency. Therefore, the preventive sector, in contrast to the medical sector, is not easily commoditized and therefore not marketable. Then, on the one hand, the government has not increased too much funding and manpower input to the prevention department. On the other hand, the prevention department has no incentive for private capital to produce goods, so it will not invest capital. Therefore, compared with the private capital of the medical department, the continuous increase Expansion and accumulation, the prevention sector does not have the phenomenon of continuous expansion and accumulation of capital. We have seen the development of Taiwan's public health system after the 1980s. When the medical department continued to expand, the prevention department did not expand or even shrunk. The situation, this process, the Taiwanese call the "medicalization" of the public health system.

Because after the mid-1980s, there was a big reversal in the entire economic policy, that is, obvious marketization and neo-liberalization, and this policy reversal certainly began to affect the public health and medical system. Then in 1995, Taiwan began to implement national health insurance. We must know that Taiwan's national health insurance is a kind of social insurance, not a social welfare system, and the medical sector is still commercialized and market-oriented. The launch of the national health insurance has made public and private hospitals alike. The government treats public and private hospitals equally, and pays you as long as you provide services, regardless of whether you are a public or private medical institution. The government used to strongly support public hospitals, but later it became less and less supportive, because the government tax revenue has also been reduced, and there is no sufficient funds to subsidize public hospitals. Therefore, the government requires public hospitals to be responsible for their own profits and losses, which in turn encourages private capital. into the medical field. Therefore, the public health system has become the result of "the marketization of the medical department, the dwarfing of the prevention department, and finally the medicalization and weakening of the public health system".

Mainland China’s policies on private capital investment in the medical system are similar to those in Taiwan in many respects. It is a policy to encourage private capital. For example, Taiwan offers tax incentives, medical development fund assistance, public and private sharing of national health insurance funds, and stimulates and encourages private or consortium capital. Into the construction of the hospital. The same goes for the mainland. In the 1980s, private hospitals continued to rise, and public hospitals basically failed to catch up with private hospitals.

A comparative analysis of the history of the public health systems in Taiwan and the mainland can give us a lot of inspiration. Looking at the development of the public health systems on both sides of the strait from an international and historical perspective, we can understand that the two sides actually share a common destiny. . Whether it is Taiwan's universal health insurance or the mainland's universal basic medical insurance, it is helpful to the public's financial burden on medical care. For example, at least the public is less likely to go bankrupt due to serious illness and pay high medical expenses. The essence of medical insurance is the sharing of public medical risks. For example, when a public suffers from a major disease such as cancer, they need high medical expenses, and this risk is shared with other people through insurance.

However, after 20 to 30 years of development, the medical departments of the public health system in Taiwan and mainland China have been commercialized and marketized. Investment in medical departments or institutions and capital for the production of medical products will continue to expand and accumulate. The medical sector will also continue to expand. Therefore, in turn, such capital accumulation will make Taiwan's universal health insurance or the mainland's universal basic medical insurance system unable to pay for the medical goods provided by the continuously expanding medical sector. cannot continue to operate indefinitely.

The proportion of government subsidies to the total revenue of public hospitals, that is, the degree of government support for public hospitals, has been declining sharply in the past two or three decades, whether it is Taiwan or mainland China. The mainland government's subsidy to public hospitals has dropped significantly since the reform and opening up, and it has been very low since the 1990s. Government subsidies only account for about 10% of the income of public hospitals. The proportion in Taiwan is relatively high, but it began to decline significantly in the 1980s and 1990s. Over the past decade or so, government subsidies have only accounted for less than 20% of the total revenue of public hospitals. Public hospitals on both sides of the strait have to seize the medical market just like private hospitals, so marketization is becoming more and more serious. This is a trend of medical marketization that societies on both sides of the strait have experienced.

After the mainland's reform and opening up, the government promoted the "paid service" policy of the prevention department, pushing the prevention department to the market, and greatly reducing the role of the government, which has become a very rare exception in the world. Although Denmark and other Nordic countries and the United Kingdom are capitalist countries, the governments and most people in these countries do not believe that the public health care system should be market-oriented.

Bai Bingqing and Liu Hanyu started discussing again.

For more than three years, we have seen that the new type of coronavirus has brought great harm, not only to our physical and mental health, but also to the medical staff. It also makes our lives very uneasy, and also affects our economy, society, Culture...wait a minute, it affects everything. Why do we all have to bear such a terrible harm today? One of the most important reasons is that the public health and medical system is not doing well.

Bai Bingqing said: I think people on both sides of the strait should reflect, and this reflection should be analyzed from the people's point of view, the people's standpoint, and from the fundamental direction. The capitalists in Taiwan definitely oppose, disagree with, or take this kind of analysis seriously, because we are not doing the analysis from the standpoint of medical capitalists, but from the standpoint of ordinary people, even the people at the lower levels. But with such a point of view and this standpoint for analysis, the mainland will not agree. The mainland always believes that their policies are the most respectful of the people. For example, the dynamic clearing. We have seen the most fundamental problem: that is the marketization of public health care. We have to ask, if the public health system cannot successfully prevent and control the tragic consequences of the new coronavirus infection epidemic, should the public pay the bill? Now all the costs are borne by the public. Do we have to continue to pay the bill in the future? The world has changed, and people don't know what to do.

Liu Hanyu sighed: Fame is related to several factors, and success is always the most important one. When the sense of responsibility that binds one's behavior disappears, one can do as one pleases and do whatever one wants. The imagination of the people is actually the power base of politicians. Politicians always like to confuse the people under the banner of being close to the people. The replacement of the conscious action of the individual by the unconscious action of crowds is one of the most striking features of the modern age. A group will make everyone's mistakes smaller, and at the same time let everyone's malice be infinitely magnified.

Bai Bingqing said: The "medical troubles" in mainland China shocked the world, but the government did not reflect on the public health system, but only regarded those "medical troubles" as rogues and criminals, which can fundamentally solve the "medical troubles" question? What plays a greater role in determining people's historical status is not the "true" faces of politicians and profiteers, but the understanding and feelings of future generations.

Qu Ting smiled and said to Chai Jianhua, an old Chinese doctor: "Old Chai, you have been a doctor all your life. You used to save lives and heal the wounded. Now you should think more about how we practitioners should treat this society. The world is suffering from depression. Let us It's becoming more and more incompetent."

Chai Jianhua smiled wryly but was speechless, the world is indeed sick.

 

醒悟（228）

 

228

 

当人类在与理性永恒的冲突中，感情从未失过手。真正的感情却来自于内心的相互认同。老中医柴健华与白冰清、刘汉宇、曲婷的第一次见面，就是没完没了地议论中国的医疗体制改革，因为他们都是从医者，医生的职责就是对民众的救死扶伤，因此如何让民众在病患中摆脱痛苦，获得新生，这就是个说不完的话题。

白冰清和刘汉宇谈到这些事时，并不讨论医疗中遇到的治病妙方或诊治技术，他们更关注的是国家医疗体制那些事。按照白冰清的说法，要解决民众的医疗问题，那就要对症下药，病根是在医疗体制的腐败和不完善。

刘汉宇认为内陆医疗体制的病灶在于执政者视民生为草芥，三年新冠病毒的横行，实际上是对民生认知变化的考验，也是对政府防控能力的测试。太多的谎言一直在欺骗着民众，但有时不真实的东西比真实的东西包含更多的真理。因为，当民众醒悟时，民众的忍耐也就到了极限。

老中医柴健华在国内从没与人谈论过内陆的医疗体制问题，他不敢谈，也没人与他谈这些敏感的事。他没想到自己抵达香港后，与新朋友的第一次交谈，就让他开了眼界。

这时，女护理曲婷插话了，她对柴健华说：我母亲曾在内陆当过赤脚医生，她内里从内陆移居香港时，为了适应香港的生活，她十分关注香港的医疗卫生制度。她的脑中渐渐不断丢失了大量在洗脑中过于沉重的知识，而用香港和西方的新知识来填充。她最为关注的是台湾的公卫医疗市场化。她曾在台湾学习医学，由此也常对我谈论过台湾公卫医疗市场化的问题。

曲婷说：我在母亲的安排下，年轻时也去台湾进行了医学进修。我先叙述一下台湾市场化的历史发展背景。

二战以后台湾光复，国民党1949年撤退到台湾。当时国民党在中国大陆事实上是跟地主、跟财团站在一起的，相对的，中共当然是完全不一样的，中共是跟农民、工人站在一起的。这种情况下，国民党逐渐失去了大陆人民的支持，在国共内战中溃败，不得不撤退到台湾来。这对国民党来讲真是非常沉痛的教训，所以国民党到台湾以后，它理解到台湾是它唯一可以栖息的地方，过去在中国大陆的整个教训一定要好好地反思、一定要改变。所以呢，国民党到台湾以后很快就推动了土改，在中国大陆时期，国民党是无法推动土改的，因为它跟地主是站在一起的呀，但是在台湾就比较容易，因为它还没有与台湾当地的地主、财团阶级建立起合作关系，也因为国民党在当时掌握着绝对的权力与资源，迫使台湾的地主不得不做出让步。国民党同时又推动进口替代、平均地权的政策——这是孙中山的三民主义中稍微有点社会主义倾向的民生主义政策，节制私人资本、发达国家资本是当时的主要政策方针。这是国民党在台湾建立政权开始的大约一二十年。

但是到了60年代、70年代，直到80年代的时候，就逆转了，其中一个很大的背后推手是美国。那时候，社会主义阵营在经济上有很不错的表现，对资本主义社会阵营的龙头老大美国来讲，不太乐见，担心社会主义阵营的表现好会对资本主义阵营造成负面影响，人民可能因而羡慕社会主义、转而希望他们的社会也实行社会主义。所以美国那时候就推亚洲四小龙，包括台湾、韩国、新加坡和香港，推动这四个地区的出口导向经济政策，目的是让这些地区的经济成长更快速些，也可以作为资本主义阵营的表率，对抗社会主义阵营。

有趣的是大陆当时也竭力宣传亚洲四小龙的经验。大陆推行了出口导向的政策，经济政策就慢慢的从节制私人资本、发达国家资本，转向鼓励私人资本的扩张及积累、减缩国家资本的政策。

曲婷说：我是在80年代中去台湾进修医学的。那时与国际情境相对应的，在台湾就是“新自由主义”的兴起，松绑、私有化，在台湾有另外一个词，叫“组织再造”，也就是市场化改革：减肥、裁员，越来越市场化。台湾从60年代开始一直到今天，市场化是一个历史发展过程。

在这样的一个经济发展市场化的情境之下， 50、60、到70年代中期，台湾的公共卫生政策主要是预防重于治疗，主力是把基层卫生建设好，而且投入很多精力到公立医院的建设。这样的政策到70年代末、80年代就很明显地开始逆转了。随着这个经济及公卫政策的逆转，公卫体系开始医疗化——所谓“公卫体系医疗化”，就是在公卫体系的预防及医疗两大部门中，医疗部门无论在经费及人力都占绝大的比例，而预防部门则相对占十分低的比例。这个时期，政府和私人资本开始大力投入到医疗部门，政府也开始鼓励私人资本投入到医疗领域。再加上私人资本会不断扩张、不断积累的规律，医疗部门就不断的扩大，相对的，政府对预防部门的投入是微弱的、也并没有因应台湾民众的疾病形态从传染病为主转移到慢性病为主的变化而有所增长。不仅台湾有这个变化，大陆其实也有这个变化。

曲婷继续说道：我们稍微分析一下医疗部门及预防部门在商品化方面的差异。我认为医疗机构提供的医疗服务比较容易转化为商品，因为绝大多数医疗服务都是个人性的，也就是针对个人需要或需求、可以标准化的、可以数量化的，因此医疗部门提供的服务比较容易商品化，而商品化之后，接着就会市场化。反之，预防部门提供的服务，如环境卫生、传染病防治等，比较不是个人性、而是公共性的，例如环境卫生的工作是为集体、而不是个人，而且多数不容易标准化、也不容易数量化，因此多数预防性服务不能转换为商品、不能被买卖、也因此无法用货币来等价交换。因此，预防部门，相对于医疗部门，是不容易商品化的，因此也就不会市场化。那么，一方面政府对预防部门并没有增加太多的经费及人力投入，另一方面，预防部门对私人资本并没有商品生产的诱因、所以不会投入资本，因此相对医疗部门的私人资本不断的扩大及积累，预防部门并没有资本不断扩大及积累的现象。我们看到的台湾公卫体系1980年代后的发展是，当医疗部门不断扩大的时候，预防部门没有扩展、甚或减缩，这就形成公卫体系的医疗部门不断扩大、而预防部门相对侏儒化的情况，这个过程，台湾人称为公卫体系的“医疗化”。

因为80年代中期以后，在整个经济政策上有很大逆转，即明显的市场化、新自由主义化，而这样的政策逆转当然开始影响到公卫医疗体系。接着1995年台湾开始推行全民健保，我们要知道，台湾的全民健保是一种社会保险、并不是一种社会福利制度，而医疗部门还是商品化、市场化的。全民健保的开办反而让公立和私立医院雨露均沾，政府对公私立医院同等对待，只要你提供服务就支付你，不管你是公立的或私立的医疗机构。政府从前对公立医院是大力支持的，后来就越来越不支持了，因为政府税收也减少了，没有充裕的经费补助公立医院，因此政府就要求公立医院自负盈亏，反过头来却鼓励私人资本投入到医疗领域。因此公卫体系就变成“医疗部门市场化、预防部门侏儒化、而最后公卫体系医疗化及弱化”的后果。

大陆对私人资本投入医疗体系的政策有很多地方跟台湾类似，就是鼓励私人资本的政策，比如台湾是租税优惠、提供医疗发展基金辅助、全民健保资金公私立共享，而且刺激和鼓励私人或财团资本投入医院的建造。大陆也是如此。80年代私立医院就不断上升、公立医院基本上就赶不上私立医院了。

将台湾与大陆的公卫体系的历史比较分析，可以给我们很多的启示，从国际的角度、从历史的角度看两岸公卫体系的发展，我们可以理解到，其实两岸是有共同的命运的。无论是台湾的全民健保或大陆的全民基本医疗保险，对民众的医疗经济负担是有帮助的，例如，至少民众比较不会因为生重病，为了要支付很高的医疗费用而倾家荡产。医疗保险的本质是民众医疗风险的共同分担，比如民众发生重大的疾病如癌症时需要很高额的医疗费用，通过保险与其他人共同分摊了这种风险。

但是，台湾及大陆的公卫体系医疗部门，经过二三十年的发展，都已经商品化、市场化了，投资医疗部门或机构、生产医疗商品的资本，会不断的扩张、不断的积累，医疗部门也会不断的扩大，因而，反过头来，这样的资本积累会让台湾的全民健保或大陆的全民基本医疗保险制度，因为无法支付不断的扩张的医疗部门所提供的医疗商品的费用，而无法永续经营下去。

政府补助占公立医院总收入的比例，也就是政府对公立医院的支持度，无论是台湾或中国大陆，过去二三十年来一直在急剧下降之中。大陆政府对公立医院的补助，从改革开放之后，明显下降，在90年代以后就很低了，政府的补助大概只占公立医院收入的一成左右。台湾的比例比较高一点，但也在1980–90年代开始明显下降之中，过去十多年来，政府的补助只占公立医院总收入的20%以下了。两岸公立医院就不得不跟私立医院一样，去抢占医疗市场，所以市场化也就越来越严重，这个是两岸社会共同经历的医疗市场化的趋势。

大陆改革开放之后，政府推动预防部门的“有偿服务”政策，将预防部门推向市场，让政府的角色大幅减低，变成国际上十分罕见的例外。虽然丹麦及其他北欧国家和英国，是资本主义国家，但这些国家的政府和多数人民并不认为公卫医疗体系应该市场化。

白冰清和刘汉宇又议论了起来。

三年多来，我们看到新型冠状病毒带来非常巨大的危害，不仅是对我们身心健康的危害，也让医疗人员极度辛苦，也让我们生活得非常不安，也影响我们的经济、社会、文化……等等，它的影响是方方面面的。为什么我们今天全民必须承受这么惨痛的危害？很重要的原因之一就是公卫医疗体系没有做好。

白冰清说：我认为两岸的人民都应该去反思，而且这个反思要尽量从人民的观点、人民的立场来做分析、从根本的方向来分析。这样的分析，在台湾的资本家一定反对，一定不赞同，一定不以为然，因为我们不是站在医疗资本家的立场，而是站在一般人民的立场，甚至是比较底层人民的立场来做分析的。但用这样的观点、以这样的立场作分析，大陆也不会同意，大陆总认为他们的政策就是最体表人民的。比如那个动态清零。我们已经看出最根本的问题：那就是公卫医疗市场化的问题。我们要问，公卫体系无法成功防治新冠病毒感染流行的惨痛后果，要民众买单吗？现在所有的代价，都让民众去承担，我们难道未来都一样要继续买单吗？这个世界变了，变得民众无所适从。

刘汉宇叹息道：名望的产生与若干因素有关，而成功永远是其中最重要的一个。束缚个人行为的责任感一消失，人便会随心所欲，肆意妄为。民众的想象力其实是政客的权力基础。政客们总爱打着亲民的旗号盅惑民众。群体的无意识行为取代了个体有意识的行为，这是现时代最显着的特征之一。群体会让每个人在其中的错误缩小，同时让每个人的恶意被无限放大。

白冰清说：中国大陆出现的“医闹”震惊了世界，但政府没有从公卫体系制度上作反思，只是将那些“医闹”视为无赖和罪犯，这能从根本上解决“医闹”问题吗？在决定人们历史地位上起着更大作用的，不是政客和奸商们的“真实”面目，而是后人对他们的认识和感受。

当人类在与理性永恒的冲突中，感情从未失过手。真正的感情却来自于内心的相互认同。老中医柴健华与白冰清、刘汉宇、曲婷的第一次见面，就是没完没了地议论中国的医疗体制改革，因为他们都是从医者，医生的职责就是对民众的救死扶伤，因此如何让民众在病患中摆脱痛苦，获得新生，这就是个说不完的话题。

白冰清和刘汉宇谈到这些事时，并不讨论医疗中遇到的治病妙方或诊治技术，他们更关注的是国家医疗体制那些事。按照白冰清的说法，要解决民众的医疗问题，那就要对症下药，病根是在医疗体制的腐败和不完善。

曲婷笑着对老中医柴健华说道：“柴老，你从医一辈子，以前是为救死扶伤，现在应该多思考一下，我们这些从医者应该如何救治这个社会了，这个世界患了忧郁症，让我们变得越来越无能了。”

柴健华苦笑而无语，这世界确实患病了。

 

 

Wake up（227）

 

227

 

The reform of China's medical system is an endless topic. The old Chinese doctor Chai Jianhua talked about these things with Bai Bingqing and Liu Hanyu, and they talked endlessly.

At this time, Qu Ting, a female nurse, interjected. Her mother had worked as a barefoot doctor in the inland area, so she paid close attention to medical hygiene since she was a child. She said: When Premier Wen Jiabao took office, he pointed out that medical care must adhere to the direction of public welfare. Perhaps more mainlanders believe that the correct health care reform plan that the society is looking forward to will surely pave the way for a virtuous circle in the future. However, the health care reform plan that has been long-awaited by all parties in the society for many years has been delayed due to various reasons, and widespread public grievances have accumulated. Although there are various small-scale or local "improvements", they are all scratching the surface, unable to match the national tide and being washed away without a trace.

Since the outbreak of the financial crisis in the United States, some impatient Chinese people thought that the era of China was just around the corner, and they linked it with the medical reform problems accumulated in the United States over the years, creating a sense of superiority from looking at the fire from across the ocean. Once American politics collapses and international interference ceases, many of China's difficult problems will be solved, including the issue of health care reform. This is an unrealistic misjudgment. Indeed, the financial turmoil sweeping across the powerful countries in the United States and Europe started suddenly and violently, and fully exposed the greedy essence of capitalism. In a sense, it does give China, which is trying to rise peacefully, a once-in-a-century opportunity. However, a body that has been ill for a long time cannot go into battle lightly, let alone bear the burden of history. But how many Chinese people are seriously reflecting on their own problems? In fact, medical care is not the only social problem that has been unresolved in China for a long time. As far as the US health care reform is concerned, it is true that the US system has many problems. But reading history must be understood. The perfect public welfare system in the United States after the war began in the 1960s, and it was healthy and effective in both public and private aspects. At that time, the American economy was growing rapidly, and the proportion of public investment was also the highest. caused by forced atrophy. Although it is still growing, it lags behind the medical expenditure of the whole society. It can be said that without the government's forced increase in investment, the medical system of the public welfare sector will be more difficult, and it is likely to have already been ruined.

Qu Ting said, I once studied medicine in the United States. What I just said actually looks like an interesting paradox. The capitalist United States seems to be repeating the mistakes of the extreme public welfare system in the past three decades, while socialist China is tasting the "market economy" of medical care. consequences. Another paradox of medical reform is that what he wants to change, that is, privatization and marketization, are the mainstream and core of the reform tide. And the elements he wants are precisely the one big and two public, eating a big pot of rice, extreme public welfare, etc. that are denied by the tide of reform. No one has the intention to turn a blind eye to the ills that were revealed at the beginning of the reform, but in the era of emancipating the mind, people are willing to believe that this is a by-product of the reform, which can be absorbed through deepening reform and social assimilation. Therefore, in fact, public welfare undertakings, which should be done with caution and acted after thinking twice, are just at the forefront of reform.

Bai Bingqing said: Qu Ting is right. Taking the epoch-making 1979 as a watershed, the extreme medical public welfare system in the first three decades made the medical industry represent a typical example of "big pot rice syndrome". The medical system is inefficient, wasteful, overstaffed, and the distribution of health resources is seriously unfair, which has become a heavy burden on the social economy. Because of this, with the tide of the reform era, the medical industry, as a serious loss-making institution, also bears the brunt of "household production contract". On the one hand, the abolition of universal medical care at public expense and the responsibility of various enterprises and institutions overnight excludes most urban and rural residents from medical insurance and other social security systems such as pensions, or the level of social security is very low. It was not until recent years that the social medical insurance system had a difficult start. Due to the lack of support, the service effect is not good, and the coverage ratio is very low, it is difficult to win the favor of policyholders, which in turn limits its development. The new rural cooperative medical system "New Rural Medical Care", which is newly born to serve farmers, is jointly funded and established by the state and farmers. Due to the small scale, it can only cover a small proportion of the cost of serious illnesses, and it does not guarantee the outpatient services that farmers use the most. As a result, it is difficult for urban and rural residents to have a sense of security in terms of health and financial resources. The concept of small farmers such as "saving for retirement" and "saving for disease prevention" has regained a strong vitality in our ancient nation, which has made the current economic crisis worse because of the lack of exports and the urgent need for domestic demand.

On the other hand, the government has stopped subsidizing hospitals. In recent years, the government’s public financial investment in medical care is less than 17% of the total medical consumption, which is less than one-third of that in the United States. Most of them are concentrated in big cities and large hospitals, and there is a shortage of medical care in small towns and rural areas. less medicine. In this way, the latter is forced to be responsible for its own profits and losses, actively charge fees, seek a way out of the market, and seek to make a fortune. So the doctor changed from an angel in white to a "white-eyed wolf", asking for red envelopes, prescribing expensive medicines, and conducting expensive examinations. Medical expenses are rising year by year and fall directly on patients. Due to the blockage of medical expenses, many people do not go to the hospital until they are "critically ill", thus missing the best time for treatment. the

Bai Bingqing said angrily: "What's more extreme is that if you ask for a huge sum of money before being hospitalized, otherwise you will refuse treatment, which will cause delays and even death for many patients due to economic reasons. When these gradually become the social norm and "common sense", it becomes difficult and expensive to see a doctor, and poverty due to illness has become a difficult pain for the Chinese people.

Liu Hanyu interface said:

The above-mentioned phenomenon mentioned by director Bingqing is not surprising at all. Since market means are used, don't be surprised that market rules mean that bad money chases good. Hospitals and doctors have become stores and salespersons. Of course, they must use value to judge what products to give to customers. Their lives and development depend on it. However, medical services are neither ordinary commodities nor luxury goods. The sentient beings who are struggling and crowded in the hospital do not have the leisurely mind to shop in the store. They are buying necessities that are often expensive. What they care about is the health and life of themselves and their families, rather than the income of the service providers. They often do not have social security, or even have financial problems, and need and count on hospital support. In their eyes, the hospital should represent the government more than the store. The huge gap between the two concepts has resulted in a great reduction in the services required by patients, and medical personnel and institutions have also borne the brunt of unprecedented pressure and accusations. It is common for doctors to be beaten and accused, and hospitals are also struggling to cope with lawsuits. What makes such a noble and respected profession a much-reviled one? Why are medical personnel and institutions also bearing the brunt of unprecedented pressure and accusations? The fundamental reason is not that people are not old-fashioned and morality is low. It is that the government has got rid of the burden of duty, but the burden has not disappeared, but falls on those who should not bear it, causing both doctors and patients to compete and confront each other under the environment of limited medical resources, and both sides suffer. Make social harmony far away.

Bai Bingqing said angrily:

If the success or failure of the first three decades is a manifestation of the extreme public welfare system. The success or failure of the next three decades is the lack of a universal medical security system and extreme marketization under government investment.

A higher standard of living can reduce the government's investment burden, but even at the level of developed countries in Europe and the United States, the government still has to continue to invest a large proportion of investment to maintain the level. For example, the United States invests more than 40%-50% of the total medical expenses every year. In China, where the per capita income level is relatively low, without large-scale government investment and support, it is impossible to maintain normal and adequate medical services. The patient would immediately be in trouble, and society would pay a heavy price for it, in the absence of lasting and stable social harmony. Therefore, the center of the reform must be to recover the lost government investment and to operate in a public welfare mode. Establish a universal health insurance system.

Liu Hanyu said to Chai Jianhua:

In short, the current medical reform in China should be different from usual. The government should have a clear understanding of the pros and cons of the medical reform practice and the future direction. It is not a return to the public medical system with one major and two formulas, but a health security system that involves the participation of all people and is enjoyed by all. In the form of a “government-led” social welfare system that covers all the people, the government should not only bear most of the start-up funds for the establishment of insurance systems at all levels, especially rural cooperative medical care, but also continue to make substantive investments. Only in this way can we ensure the healthy and sound operation of this system and ensure the health and stable life of the whole people.

Liu Hanyu sighed to Chai Jianhua: It's a pity that the Chinese government can't do this. Now that you move to Hong Kong, you don't have to worry about your medical insurance. In the 1970s, Hong Kong’s economy was still relatively backward. In addition, the British colonialists of that era were all ruled by "powerful power" and "scraping money for the ancestral home (Britain)", so they paid little attention to the livelihood of the Hong Kong Chinese. There were also "public hospitals" at that time, but there were too many monks and too little food. Poor people had to spend half a day in the scorching sun or cold wind to get a "chip (number)", and waited for hours to see a doctor for a few minutes. The cost is quite cheap, a few cents. Those with better financial conditions will find "private doctors". Public hospitals also allocate part of their resources for richer patients, called "private rooms". These charges are on par with private hospitals, plus they are government-funded, so there are also some world-class famous doctors. But the charges can only be afforded by at least the upper-middle-class people in the society. Even if you enter a public hospital, you have to spend more "red envelopes" to the general staff, otherwise even if you live in a "private room", you have to go to fetch water yourself. And almost all private hospitals also have to accept emergency patients such as car accidents. Many private doctors with good medical ethics will set up outpatient clinics in the streets, and treat neighbors with relatively low fees, which can be accepted by working people with stable incomes. Generally speaking, the medical care in Hong Kong at that time was insufficient and not affordable for the working people, which also made domestically produced Chinese patent medicines very popular among the working people in Hong Kong. For example, "Yinqiao Jiedu Tablets", "Bao Chai Pills" (later changed to Kangning Pills due to registration issues), "Liushen Pills", etc., the proprietary medicine department of the domestic product company occupies a considerable place. By the way, during the Vietnam War, many U.S. troops who invaded Vietnam through Hong Kong went to domestic companies to snap up "Yunnan Baiyao" (it is said that it can pull shrapnel out of the muscles, but the effect of the drug on blood disinfection and blood accumulation is my own experience. So far it is still my family’s regular guardian medicine), and "Pian Tze Huang", which is a liver-protecting and liver-curing medicine, is now sold for more than 100 yuan a pill. The U.S. military is afraid that the miasma in the tropical forest will be unhygienic. Take it to strengthen the liver and strengthen immunity , This time of pneumonia, doctors also use it to cooperate with other treatments. There is also an orthopedic medicine "Bone-setting Water" divided into "Yunxiangjing" and so on.

Medical care in Hong Kong began to change in the 1980s. In fact, it is inseparable from the struggle of the Chinese descendants against the colonialists, which forced the British to change the deprivation and oppression of the Chinese residents in Hong Kong. This was the "Anti-British Rebellion" in 1967. It was precisely because of this vigorous patriotic mass movement that the British colonialists were forced to adopt a softer policy towards Hong Kong, and they no longer dared to steal the fruits of Hong Kong people's hard work back to the UK, but returned Hong Kong people's hard work to Hong Kong. Back then, the domestic situation provided Hong Kong with a large amount of cheap labor, making Hong Kong one of the four Asian tigers and laying the economic foundation for Hong Kong's medical care. Since the 1980s, Hong Kong has basically achieved free or low-cost medical care for all.

Liu Hanyu told Chai Jianhua that at that time, I left the mainland and returned to work and live in Hong Kong. Hong Kong basically has a relatively complete medical system with Western medicine as the main body. There is no "street wheel syndrome" for minor illness registration, that is, queuing on the street. Usually you can see a doctor within three days. Because during this period of time, the young and strong (28-45 years old) seldom see a doctor, and they are also busy with work, and they care less about the society. I can only use a few examples to talk about it. I have a friend who immigrated to Canada. He was diagnosed with cancer at an early stage in Canada, and waited half a year in Canada for surgery. He immediately flew back to Hong Kong and had surgery in the public medical system that month. The cost was similar to that in Canada. Canada was free of charge. Hong Kong only paid a few dozen yuan for registration and a daily hospitalization fee. Canada allows dual citizenship, and Hong Kong also allows Hong Kong permanent resident status, so Hong Kong people immigrating to Canada can use Hong Kong's public medical system. Although Canadian critical care public medical care is good, the queues are long and the cost is high.

 

醒悟（227）

 

227

 

关于中国医疗体制改革，是个说不完的话题。老中医柴健华与白冰清、刘汉宇谈到这些事，也就说个没完没了。  

这时，女护理曲婷插话了，她的母亲曾在内陆当过赤脚医生，因此她从小就非常关注医疗卫生。她说：温家宝总理任职时曾指出，医疗事业必须坚持公益性方向。也许更多的大陆人认为社会翘首以盼的正确的医改方案，必为将来的良性循环开拓先声。但多年来社会各方早已千呼万唤的医改方案，却因各种原因拖沓日久，广积民怨。虽有各种小规模的或地方性的“改良”，但都属隔靴搔痒，无法匹敌全国性的大潮而被冲得无踪无影。

美国金融危机爆发的以来，一些心急的国人以为中国时代已经呼之欲出了，又和美国多年积累的医改问题联系起来，产生一种隔洋观火的优越感。美国政治一旦崩溃,国际干扰不再，中国许多难以解决的问题就会迎刃而解,包括医疗改革问题也会柳暗花明，甚至可绕道而走。这是不切实际的误断。 确实，这场席卷美欧强国的金融风暴事起突然，来势凶猛，且将资本主义的贪婪实质暴露无遗。某种意义上，确实给企图和平崛起的中国一个百年不遇的契机。然而久病之躯是无法轻装上阵的，更遑论承担历史重负。但有多少国人在认真反思自身的问题呢？其实，中国目前久积未决的社会问题何止医疗保健一项？仅就美国医改问题而言，确实美国体制问题重重。但读史一定要读懂。战后美国完善的公益体制起自60年代，在开始公私两面健康有效，而那时美国经济成长迅速，公共投入的比例也是最高的，最后的困难重重正是与经济面每况愈下，医疗投入亦被迫萎缩所致。尽管依然增长却滞后于全社会医疗花费。可以说若没有政府被迫增长的投入，公益部分的医疗系统将更加艰难，很可能早已破败。

曲婷说道，我曾在美国学医。我刚才说的，其实很像是一个有趣的悖论，资本主义的美国似乎开始重蹈着我们前三十年的极端公益制的覆辙，而社会主义的中国却在品尝着医疗“市场经济”的恶果。医改的另一悖论是，他要改的东西，也就是私营化、市场化，这正是改革大潮的主流和核心。而他所要的元素，恰恰是改革大潮所否定的一大二公，吃大锅饭，极端公益性等等。任何人都无意视而不见改革之初就已显露的弊病，但在解放思想的年代，人们愿意相信这是改革的副产品，可以通过深化改革和社会同化吸收。因而事实上，本应谨慎而行，三思后而动的公益事业事却恰恰走在改革的前排。

白冰清说：曲婷说的不错。以划时代的1979年为分水岭，前三十年的极端医疗公益制使医疗行业代表着“大锅饭综合症”的典型。医疗体系效益低下，浪费惊人，人浮于事，卫生资源分配严重不公，成为社会经济的沉重负担。正因如此，随着改革时代的大潮，作为严重亏损机构的医疗行业也首当其冲“包产到户”了。一方面取消全民公费医疗改为各企事业单位负责， 一夜间将大多数城乡居民排除在医疗保障及其它社会保障如养老等制度之外，或者社保水平很低。直到近几年社会医保系统才艰难起步。由于缺乏支持，服务效果不彰，覆盖比例很低，难以获得投保人青睐，反过来限制它的发展。新生的为农民服务的新型农村合作医疗制度“新农合”，由国家和农民共同出资建立。由于规模很小，只能覆盖大病时的小比例的费用，且不保障农民使用最多的门诊服务。由此无论城乡居民都难有健康和财力的安全感。“储蓄养老”，“储蓄防病” 等小农观念在我们这一古老民族的恢复了强大活力，这在此次经济危机出口不足和急需内需的窘境雪上加霜。

另一方面政府停止资助医院，近年来政府在医疗的公共财政投入不足医疗总消费的17%，不及美国的三分之一,且多向大城市大医院集中,小城镇和广大农村更加缺医少药。 如此就逼迫后者自负盈亏，积极收费，从市场中谋出路，谋发财．于是医生从白衣天使变成“白眼狼”，索受红包，开昂贵药，作昂贵检查。 医药费逐年上升且直接落在病患者身上。由于医药费的扼阻，许多人不到“病危”不去医院，由此错过了最佳的治疗时机。　

白冰清愤怒地说道：更极端的是，住院先索取巨款，否则拒绝救治，令许多病者因经济原因而延误甚至致死，见义勇为受伤者亦不能幸免。当这些逐渐成为社会常态和“常识”，看病难，看病贵和因病致贫由此成为中国人的难隐之痛。

刘汉宇接口说道：

冰清主任说的上述现象一点也不奇怪。既是用市场手段，就不要惊讶市场规则恶币逐良。医院和医生成为商店和售货员，他们当然要用价值来判断给与客户何种商品。他们的生活和发展全系于此。然而医疗服务却不是普通商品更不是奢侈品。艰难拥挤在医院里的众生可没有在商店里购物的悠闲心态。他们是在购买经常是昂贵的必需品。他们关心的是自己和家人的健康和生命，而不是服务者的收入，他们往往没有社会保障，甚至他们的经济有问题，需要而且指望医院支持。在他们眼里医院应比商店更代表政府。两种观念的巨大鸿沟造成病人所需服务的极大缩水，而医务人员和机构也首当其冲地承受着前所未有的压力和指责，医生被打被告司空见惯，医院也在诉讼中艰难应付。是什么使这样一个高尚和受人尊敬的职业变成备受责难的职业？为何医务人员和机构也首当其冲地承受着前所未有的压力和指责？根本原因不是人心不古，道德低下。而是政府摆脱了责无旁贷的包袱，但包袱没有消失，而是落在不该担负者的身上，致使医患双方在有限的医疗资源环境下相互竞争和对立，两败俱伤。使社会和谐遥遥无期。

白冰清愤怒地说道：

如果说前三十年的成败是极端公益制的体现。后三十年的成败，就是缺乏一个全民医疗保障制度和政府投入下的极端市场化。

较高的国民生活水平可以减低政府的投入负担，但即使如欧美发达国家的水平，政府依然要持续投入大比例的投资维持水平。如美国每年投入医疗总花费的40％－50％以上。而在人均收入水平较低的中国，如没有政府大规模投入和扶持，正常和足够的的医疗服务是不可能维持的，这一问题不解决，社会广大成员长期无法享受足够的医疗服务，不仅患者会立即陷入困境，社会也要为此付出沉重代价，无法获得持久和稳定的社会和谐。因而改革的中心必然是找回就已失去的政府投入和以公益性的运作模式。建立一个覆盖全民医疗保障制度。

刘汉宇对柴健华说道：

总之，目前中国的医改应不同往常。政府应该认清医改实践的得失和今后的方向，不是回到一大二公式的公费医疗体制，而是一个有全民参与，全民享有的健康保障体系，一种近乎医疗保险，合作医疗等多种形式的覆盖全民的，“政府主导”的社会公益体系，即政府不仅要承担建立各级保险体系，尤其是农村合作医疗的大部分启动资金，且要持续地加以实质性投入。这样才能保证这一体系健康良好地运作下去，保证全民的健康和安定的生活。

刘汉宇对柴健华长叹道：可惜中国政府做不到这一点。你现在移居香港，不用为自己的医保担心了。70年代的香港经济仍比较落后，加上那时代的英国殖民主义者都是“强权统治”加“为祖家（英国）刮钱”统治，所以对港华人民生极不关注。那时候也有“公立医院”，但僧多粥少，穷人要在烈日或寒风中轮上半天才取得一个“筹（号）”，再排几小时才见医生几分钟。费用则相当便宜，几毛钱。经济好点的都找“私家医生”。公立医院也拨出部分资源用作较富的病人，叫“私家房”，这些与私立医院收费水平看齐，加上是政府的，所以也有一些名医到世界水平的。但收费至少社会上经济到中上的人才能负担。即使进了公立医院，也得花更多的“红包”给一般工作人员，否则即便住“私家房”，连打水都要亲自去。而几乎所有的私人医院，也须接受紧急病人如车祸等。不少私人医生医德较好的会在街道设门诊，以较低收费为街坊诊病，收费水平可为有稳定收入的劳动群众接受。总的来说，那时的香港医疗是不足的，也非劳苦大众可负担，这也令国产的中成药在香港很为劳苦大众欢迎。如《银翘解毒片》，《保济丸》（后因注册问题改为康宁丸），《六神丸》等，国货公司内的成药部占相当地方的。顺便一提，越战时，不少经港侵越的美军，都到国货公司抢购《云南白药》（据说可把弹片从肌肉中拔出，但该药上血消毒散积血效果是我亲历的，至今它仍是我家庭的常备守护药），还有《片仔癀》，是护肝治肝药，现卖过百元一粒，美军怕在热带林中瘴气重不卫生，服用它强肝强免疫，这次肺炎亦有医师以它配合其他治疗。更有骨科药《正骨水》分《云香精》等。

香港80年代的医疗开始改变了。其实离不开一次中华子孙对殖民主义者的斗争，令英国不得不改变对香港华人居民的剥夺与高压。这就是1967年的“反英抗暴”。正因为这一次轰轰烈烈的爱国群众运动，才迫使英国殖民主义者对香港采取较为怀柔的政策，也不敢再把香港人努力的成果偷回英国，而把香港人的努力回报香港。当年因国内形势而为香港提供了大量的亷价劳力，令香港成为亚洲四小龙之一，也为香港的医疗打下经济基础。从80年代开始，香港已基本做到全民免费或低费医疗。

刘汉宇对柴健华说，那时，我离开内陆，回到香港工作、生活。香港基本上已有一个较完整的以西医为主体的医疗系统。小病挂号不用“轮街症”，也就是在街上排队。一般都可以三天内看上病。因为这段时间年青力壮（28-45岁）的很少看医生，也为工作奔波，较少关心社会，只能用几个实例说一下。我有移民加拿大的朋友，他在加拿大查到癌症早期，在加拿大排队半年后手术。他马上飞回香港，当月就在公立医疗系统做手术，费用与在加拿大差不多，加拿大全免，香港只付几十元的挂号与每天几十元的住院费。加拿大允许双重国藉，而香港也允许保留香港永久居民身份，所以移民加拿大的香港人都可以使用香港的公共医疗系统。加拿大重症公费医疗虽好，但是排队长以及成本高。

 

Wake up（226）

 

226

 

Bai Bingqing and Liu Hanyu talked about China's medical and health care to Chai Jianhua. They both talked about the publicity and marketization of public health care in mainland China.

Bai Bingqing said that in the 30 years after the founding of the People's Republic of China, mainland China has basically developed a state-owned economy, attached importance to public welfare, emphasized collectivism based on mobilizing the masses, and the spirit of social equality. Deliberately downplay the role of the market. It's not that there is no market at all, but try to reduce it as much as possible. Therefore, under such circumstances, the public health medical system in the first 30 years was based on the principle of "prevention first, treatment as supplementary", and there was cooperative medical care. In a collective way, barefoot doctors stood in the local township or people's commune. From the standpoint of farmers/villagers, to promote sanitation and medical work, it pays great attention to rural health care and the integration of traditional Chinese and Western medicine, but it is not so medical, and it is the combination of mass movement and health care work. At that time, the public health and medical systems of most countries in the world followed the Western model. This model focused on medical care, focused on personal medical services, relied on high-tech specialists, and emphasized high medical technology standards. However, after the founding of the People’s Republic of China, the CCP abandoned this mainstream Western model at that time and created its own unique public health medical system.

Bai Bingqing also said that after 1978, especially after Deng Xiaoping's southern tour, what we saw was market-oriented reforms. The original public sector, enterprises and institutions are either privatized, or they are responsible for their own profits and losses and let them seek their own way of survival. The disintegration of the rural people's communes emphasizes individual responsibility—if there is a problem, it is because you are not working hard enough, so you must be self-reliant and tolerant of social inequality. The social inequality in mainland China is very serious now. Compared with other countries in the world, the social inequality in mainland China is also very prominent.

The public health and medical system in the last three decades has undergone a major reversal, and it has turned its head to follow the path of the Western model. Before 1949, not only mainland China, but also most developing countries in the world followed the Western model. However, after the founding of the People's Republic of China, the mainland chose to go its own way: the public health and medical system rejected the Western model and established its own unique model, which made the world look at it with admiration. The mainland dares to stand alone in the case of most countries adopting the mainstream Western model, stand on the standpoint of the people, and establish its own unique public health medical model, which is quite structured and courageous. However, after the reform and opening up, the mainland actually embraced the Western model that it had rejected in the past: treatment was the main focus and prevention was the supplement; communes and cooperative medical care were disintegrated, barefoot doctors disappeared, and rural doctors were forced to provide medical products to obtain their own resources. Income; medical resources shift to cities; more emphasis on Western medicine; and the government is paying more and more attention to the establishment of medical departments, and providing personal medical services has become the main task of the public health medical system; the government makes public hospitals responsible for their own profits and losses; after the 1990s, public health medical institutions They have to make profit their primary goal; the public health medical system no longer emphasizes meeting the basic health needs of the people, nor does it focus on promoting public health through mass movements, but instead focuses on medical technology and medical technology.

Liu Hanyu added: But people can't bear not being able to get medical services anytime and anywhere. Back then, going to a hospital to see a specialist required a referral. In the mid-1980s, the government removed these barriers, allowing people to be treated in hospitals. At the same time, China embarked on economic reforms that led to the disintegration of the entire healthcare system. Government subsidies have been slashed, and hospitals have had to find ways to generate revenue.

Medical students were drawn to hospitals as they began investing in high-tech equipment and expanding to meet new financial needs. Many believe that being a specialist guarantees them an "iron job" and that specialist jobs come with extensive security, including housing and pensions.

Liu Hanyu sighed: Not long ago, a man had an argument with the doctor about his daughter's treatment and attacked the doctor. A month ago, a father slashed a pediatrician 15 times after his daughter died shortly after birth. The doctor did not survive. A few hours ago, a patient surnamed Lu stabbed a doctor who had treated him for rhinitis with a knife at Peking University People's Hospital, and then fled. After the police caught him, he was sentenced to 13 years in prison.

Liu Hanyu said: The reason for this kind of violence is the same, that is, distrust of the medical system. This goes back to the market reforms introduced by Deng Xiaoping in the 1980s. Doctors are being forced to find ways to generate income after the government cut subsidies to hospitals. Many received kickbacks from drug companies and gifts from patients. I've heard of outpatient doctors collecting tens of thousands of yuan in kickbacks from drug companies, bundles of cash in a plastic bag.

Corruption has become endemic. In 2014, GlaxoSmithKline paid a $500 million fine for kickbacks to doctors and hospitals that prescribed the company’s drugs, at the time the largest penalty ever imposed in China. Eli Lilly, Pfizer and other global drug giants have also settled with regulators for similar conduct. In fact, these factors combined to create violence. Many hospitals are starting to take steps to protect staff. For example, Guangzhou Zhongshan Hospital employs taekwondo coaches to teach doctors self-defense skills. Hospitals in Jinan paid for security companies for protection.

In order to solve the problem of difficult medical access, the Chinese government aims to increase the number of general practitioners per 10,000 people from the current 1.5 to two to three, and finally to five. But to get there, at least first, China needs to train thousands of doctors who have no idea how primary care is done and no interest in leaving their comfortable jobs in public hospitals.

There has been a change in the proportion of government financial subsidies and hospital business income in the total income of public hospitals. In the past 10 years, the proportion of government financial subsidies to the total income of hospitals is less than 10% in most years, and only a little more than 10% in some years. As much medical service as possible to generate income, to supplement the income needed by the hospital, and to cover the expenditure of the hospital. Such data and trends reflect that although these hospitals are state-run or public, 90% or nearly 90% of their operations need to be self-financed from the business income from providing medical services, that is, they have Although it is called state-run or public, it is actually not much different from self-financing and private hospitals. The role of the state in the management and operation of state-run/public hospitals has basically been almost completely abdicated. That is to say, as a result of the reform and opening up, public hospitals, like private hospitals and clinics, need to earn profits from the medical market by providing medical products in order to maintain their survival or accumulate and expand their capital. This is China The main connotation of medical commercialization and marketization.

Before 1980, that is, before the reform and opening up, almost all of the funding for the prevention department of the public health system came from the government. At that time, this department did not need to provide paid services to earn income. However, with the advancement of reform and opening up, the proportion of government subsidies in the total income of prevention institutions dropped sharply from almost 100% before the 1980s to 59% in 1990, and even 42% in 1997. It rebounded slightly in 2002, but then unexpectedly dropped to 25% and 30% in 2004 and 2006. Even the lowest point was 19% in the year when the Asian financial turmoil occurred. There is a tendency that the Chinese government will almost completely give up its responsibility for the prevention department of the public health system.

At present, more than half of the income of China's preventive health institutions must be self-generated. Moreover, we know that the outbreak and epidemic of SARS had a great impact on mainland society, and the public began to reflect on the problems of the public health system. Instead, it significantly reduced its subsidy funding for the prevention sector.

Before 1980, the preventive department did not need to earn business income by itself, because its expenditure was paid by government funds. Therefore, during this period, the proportion of business income was almost zero. However, with the pace of market reform going forward, the prevention department began to use its own business income—that is, to earn income from providing paid services—to generate income and increase the total income. After the 1990s, it rose sharply, and by 2004, this proportion had risen to 75%. It can be said that the outbreak and epidemic of SARS not only failed to urge the government to pay attention to the prevention department of the public health system, but even allowed it to be responsible for its own profits and losses, earn funds from business income, and let it fend for itself. After 2012, although the proportion of increasing business income by providing paid services has slightly decreased, more than 50% of the prevention department's funds still have to be earned from the business income of providing paid services. Moreover, after three years of the tragic impact of the new crown virus epidemic, this trend has not been fundamentally reversed.

The mission of the public health system is to promote and maintain the health of the people, and the mission of the prevention department of the public health system is to prevent diseases before they occur. Preventing the occurrence of diseases is the most cost-effective and labor-saving method. On the contrary, it is the most laborious, costly, and unwise to seek medical treatment when the disease occurs without daily prevention. There are clear precepts, such as the "Internal Classics" which emphasizes that "the sage does not cure the disease and treats the disease before it", and the genius doctor Bian Que put forward the concept of "prevention is better than cure" more than 2,000 years ago.

The health of the whole people is the basis for the sound development of a country. However, the mainland government not only did not strongly support the prevention department, so as to practice the ancient wisdom of "prevention is better than cure" in Chinese culture, but instead promoted the policy of "paid services", which made the government give up its commitment to the prevention department and the health of the whole people. Promote and maintain due accountability and leave these preventive institutions to fend for themselves.

Liu Hanyu sighed: Over the past decades, I have studied and paid attention to the development of the public health system of various countries in the world, and I have never seen a country that has clearly abdicated from the development of the prevention department, let the market enter the market, and left it to fend for itself! By the end of March 2020, more than 80,000 people in mainland China have suffered from the new coronavirus disease, and more than 3,000 people have died from severe new coronavirus pneumonia. The impact of the outbreak and prevalence of this infectious disease on the mainland's economy, society, culture, people's lives, and their physical and psychological health is immeasurable. Due to the weakening of the prevention department and the inability of the prevention and health institutions to effectively prevent and control the epidemic of the new crown virus, what a price the people of the mainland have paid! But they have no choice. The whole people must pay for this huge price. The mainland government's policy of promoting marketization in the public health system has made serious mistakes, and the cost is high, from the damage caused by the epidemic of the new crown virus infection to mainland society, it is self-evident.

Veteran Chinese doctor Chai Jianhua is 96 years old, and Bai Bingqing and Liu Hanyu are both in their early 50s. There is an obvious generation gap between Chai Jianhua, Bai Bingqing and Liu Hanyu, and there are actually regional cognitive differences. The mainland's brainwashing propaganda and education have naturally had a deep impact on Chai Jianhua. Bai Bingqing and Liu Hanyu, who have lived in Hong Kong for a long time, accept Western values of democracy and freedom.

When Chai Jianhua first arrived in Hong Kong, he already felt this.

 

醒悟（226）

 

226

 

白冰清和刘汉宇对柴健华说起中国医疗卫生这些事，他们都谈到了中国大陆公卫医疗的公共性和市场化问题。

白冰清说，建国之后三十年，中国大陆基本上发展国营经济、重视公共福利事业、强调以发动群众为基础的集体主义，以及社会平等的精神，而且各种服务的提供或产品的分配上尽量刻意降低市场的角色。不是完全没有市场，但是尽量降低。所以这样的情况之下，前三十年的公卫医疗体系是“预防为主、治疗为辅”的原则，而且有合作医疗，以集体的方式，由赤脚医生站在当地乡镇或人民公社的农民/村民的立场，来推动卫生以及医疗工作，非常注重农村的卫生医疗和中西医结合，但不是那么的医疗化，还有就是群众运动与卫生医疗工作相结合。当时全世界大多数国家的公卫医疗体系都是走西方模式的，这个模式以医疗为主，注重个人医疗服务，依赖高技术的专科医生，强调高医疗技术水准。而中共建国之后，却摒弃这个当时主流的西方模式，而创立了自己独特的公卫医疗体系。

白冰清又说，1978年以后，特别是邓小平南巡之后，我们看到的情况就是有了市场化改革。将原来的公有部门、企业和机构要不就是私有化，要不就是自负盈亏、让它们自我寻求生存之道。农村的人民公社解体，强调个人的责任——假如出现问题，是你自己不够努力，所以你要自立自强，而且要容忍社会的不平等。现在大陆社会的不平等现象是非常严重的，与世界其他国家作比较，中国大陆的社会不平等的问题也是很突出的。

后三十年的公卫医疗体系发生了大逆转，反过头来走西方模式的道路。1949年之前不但是中国大陆，而且世界上大部分发展中国家走的都是西方模式。但是，当时大陆建国后却选择走自己的路：公共卫生医疗体系拒绝西方的模式，建立了自己独特的模式，让世界刮目相看。大陆敢在多数国家都采取主流西方模式的情况下，独排众议，站在人民立场、建立自己独特的公卫医疗模式，是相当有格局、有魄力的。但是改革开放之后，大陆居然就拥抱过去自己所拒绝的西方模式：以治疗为主、预防为辅；公社、合作医疗解体了、赤脚医生消失了，乡村医师被迫以提供医疗商品来获取自己的收入；医疗资源转向城市；更注重西医；而且政府越来越关注医疗部门的建立，提供个人医疗服务变成公卫医疗体系的主要工作；政府让公立医院自负盈亏；90年代之后公卫医疗机构不得不将赚取利润变成它们的首要目标；公卫医疗体系不再强调满足人们群众的基本健康需要，也不注重以群众运动来推行公共卫生，反而注重医疗科技、医疗技术。

刘汉宇补充道： 但是人们不能忍受无法随时随地得到医疗服务。那时候，去医院看专科医生需要转诊。1980年代中期，政府取消了这些障碍，允许人们在医院接受治疗。与此同时，中国开始进行经济改革，导致整个医疗制度解体。政府补贴大幅削减，医院不得不想办法来创收。

随着医院开始投资高技术设备，并为满足新的财务需求扩大规模，医学院的学生也被吸引到医院。许多人认为，当专科医生会保证他们有“铁饭碗”，专科医生的工作有广泛的安全保障，包括住房和养老金。

刘汉宇叹息道：不久前，一名男子就女儿的治疗与医生发生口角，袭击了该医生。一个月前，一名父亲因为女儿出生后不久夭折，砍了小儿科医生15刀，医生没能活下来。几个小时前，一个吕姓患者在北京大学人民医院用刀刺伤了曾为他治疗过鼻炎的医生，并随后逃走。警方将其抓捕后，他被判入狱13年。

刘汉宇说：造成这种暴力行为的原因都一样，就是对医疗体系的不信任。这要追溯回邓小平在1980年代推行的市场改革。政府削减对医院的补贴后，医生被迫想方设法创收。许多人收受了来自药品公司的回扣及病人给的礼物。我听说过门诊医生从药品公司收取数万元回扣的事，一个塑料袋装一捆一捆的现金。

腐败成了一股风气。2014年，葛兰素史克因给开出该公司药品的医生和医院回扣，支付了一笔5亿美元的罚款，在当时是中国有史以来金额最高的处罚。礼来(Eli Lilly)、辉瑞(Pfizer)和其他全球药品巨头也就类似行为与监管者达成和解。其实这些因素混合起来，造成了暴力。许多医院都开始采取措施保护员工。如广州中山医院雇佣了跆拳道教练，教授医生自卫技巧。济南的医院花钱雇了用于保护的保安公司。

为解决就医难的问题，中国政府的目标是将每一万人拥有的全科医生数量从现在的1.5名增加到两到三名，最终达到五名。但要实现这个目标，中国至少首先需要培训成千上万的医生，这些人对初级治疗该如何进行毫无概念，也没有兴趣离开他们在公立医院的安逸工作。

政府财政补助与医院业务收入在公立医院总收入中所占比例出现了一个变化。近10多年来，政府财政补助占医院总收入的比例多数年度低于10%，只有有些年度比10%多一点点而已，剩下的9成收入需要医院自己想办法：即，他们必须从提供尽量多的医疗服务这个商品来创收、来补足医院所需要的收入、来覆盖医院的支出。这样的资料及趋势反映的是：虽然这些医院是国营的或公立的，它们的经营，9成、或近9成是需要从提供医疗服务的业务收入中自负盈亏的，也就是说，它们已经虽然名为国营或公立，实际上与自负盈亏、与私立医院差别不大了。国家在国营/公立医院的经营及运作的角色，基本上几乎已经完全退位。也就是说，改革开放的结果，公立医院与私人医院及诊所一样，都需要从医疗市场中，藉由提供医疗商品赚取利润，以维持他们的生存或积累及扩张它们的资本，这就是中国医疗商品化、市场化的主要内涵。

1980年之前，即改革开放之前，公卫体系预防部门的经费几乎全部来自政府，当时这个部门是不需要自己提供有偿服务来赚取收入的。但是，随着改革开放往前推进，政府补助占预防机构总收入的比例就从1980年代之前的几乎100%急剧下降到1990年的59%，甚至1997年的42%。2002年略有回升，但是随后居然在2004年、2006年骤然下降到25% 及30%。甚至最低点到亚洲金融风暴发生当年的19%。大有中国政府几乎要完全放弃对公卫体系预防部门的责任承担的态势。

现在的中国预防卫生机构，一半以上的收入必须要自己创收。而且，我们知道，非典肺炎的爆发及流行，对大陆社会造成很大的冲击，公众也因此开始反省公卫体系的问题，但是，这样的冲击及反省，不但没有促成政府对公卫体系预防部门的经费挹注，反而大幅缩减其对预防部门的补助经费。

预防部门在1980年之前，不需要自己赚取业务收入，因为它的支出都由政府的经费来负责支付，因此，这个时期，业务收入的比例几乎就是零。但是，随着市场改革的步伐往前行，预防部门开始必须自己利用业务收入—就是从提供有偿服务来赚取收入–来创收、来增高总收入，因此预防部门的“业务收入”比例在1980年代之后就急剧上升，到2004年的时候，这个比例已经上升到75%了。可以说，非典肺炎的爆发及流行，不但没有督促政府重视公卫体系的预防部门，甚至任其自负盈亏、从业务收入中赚取经费来源、任其自生自灭。2012年之后，虽然以提供有偿服务来增加业务收入的比例稍微下降，但是预防部门经费的5成以上，还是必须从提供有偿服务的业务收入来赚取。而且，在三年惨痛的新冠病毒流行的冲击之后，这样的趋势并没有因此得到根本的扭转。

公卫体系的使命是促进与维护全民健康，公卫体系预防部门的任务则是在疾病发生前预防其发生。预防疾病的发生，是最省钱省力的作法，反之，日常不预防，等到疾病发生时才找医生治疗，则是最费力、最费钱、最不明智的作法；这个原理，我国古文化早有明训，如《内经》强调“是故圣人不治已病治未病”，又如两千多年前神医扁鹊就已经提出“预防胜于治疗”的理念。

全民健康是一个国家健全发展的基础。但是，大陆政府不仅没有强力支持预防部门、从而实践上述我国文化“预防胜于治疗”的古老智慧，反而推动“有偿服务”的政策，使得政府形同放弃其对预防部门、以及对全民健康的促进与维护该有的责任承担，让这些预防机构自生自灭。

刘汉宇感叹道：我过去数十年来，研究及关注世界各国的公卫体系发展，还没有看到一个国家这样、明显的从预防部门的发展退位、让市场进场、任其自生自灭的！ 2020年3月底，大陆罹患新冠病毒疾病的人就已经超过8万多，而因严重新冠病毒肺炎而死亡的人数已经超过3千多人。而这个传染病的爆发与流行，对大陆经济、社会、文化、人民的生活及他们的生理及心理的健康的冲击是难以计量的。因预防部门的弱化以致预防卫生机构无法有效防治新冠病毒的流行，大陆人民付出多大的代价呀！但他们别无选择，这个巨大的代价，全民必须买单。大陆政府在公卫体系推动市场化的政策是有严重的错误的，而其代价之大，从新冠病毒感染流行对大陆社会所造成的伤害，不言而喻。

老中医柴健华已是96岁的老人了，白冰清和刘汉宇都是50出头的人。柴健华与白冰清和刘汉宇有明显的代沟，其实还有区域的认知差异。大陆的洗脑宣传教育对柴健华的影响自然很深，长期生活在香港的白冰清和刘汉宇接受的是西方的民主自由价值观。

柴健华初到香港，已感受到了这一点。