From modern China to modern medicine*

C H Leong 梁智鴻

HK Pract 2002;24:553-558

With the firing of the first shot from a homemade cannon began the selfless and heroic struggle to overthrow the Manchu, Modern China was thus created. Dr Sun Yat Sen, to whom today's oration and many in the past was dedicated to honour, was not only amongst the first few to be involved in the revolution, but was also at the center pages of building the New China. Thus ended the many thousands of years of imperial rule in our motherland since the days of Huang Di, and replaced by a Republic to be governed by the people.

Yet, the concept of Modern China goes much more than the change in style and concept of governance, nor were these the only visions of Dr Sun, the father of Modern China. For with the overthrow of autocracy came also the awakening of people's rights, the equality of the genders, the need for democratisation, the right of being represented. What's more, it called for transparency of the administration and the accountability of the government and those who were put into the power to govern.

How much have these helped in the development of modern medicine and medical services of China? How much have such been instead a deterrent? Time will have them slowly unfold. Some of these have already surfaced and will form aspects of today's oration. One thing for sure, in the same light as the government, the medical profession, as the protector of people's health, is put under the close scrutiny of the microscope. They too have to be transparent and they too, like it or not, have to exhibit accountability.

Introduction of Western medicine into China

The health care system and the medical services of ancient China was a class of its own. Peasants and those from the lower social class traditionally went to folk or religious healers, for in popular thinking the supernatural was seen as a major cause of illness - sickness was generally believed to be created by demons or to be punishment for violating or neglecting one's ancestors. The elite from middle or higher social strata patronised Traditional Chinese Medicine (TCM) practitioners who were educated on the many works of medical literature, applied the art of diagnosis and provided treatment through herbal drugs and prescriptions. It is in this form that TCM has been passed down essentially unchanged since the dawn of civilisation and flourished. Regrettably, whilst TCM practice is very much based on experience and opinion, it lacks utterly in evidence based, hindering its metamorphosis into a real scientific endeavour.

The twilight years of Manchu rule was plagued with the barbaric invasion by foreign powers into Chinese soil. Along with those who brought on the onslaughters were also missionaries who introduced into China not only Western religious belief but Western medicine. Overnight, evidence based Western medicine became the saving grace. The overthrow of the Manchu became then the watershed between ancient medicine and Western (modern) medicine. The age of modern medicine has arrived. Whilst Dr Sun Yat Sen could not be claimed as the forerunner introducing modern medicine to China, he straddled two eras. Furthermore, Dr Sun was the first to graduate from a recognised Western medical school on Chinese soil. Subsequently, the newborn Modern China sought to establish a modern state medical system.

No doubt the pressure of patriotic sentiments, reinforced by anti-capitalist ideology, has led to the retention of TCM as a symbolic authority and the professional parity with Western medicine. Yet, Western medicine has come and it will stay.

Mr President, Ladies and Gentlemen, it could therefore be said that a stage is set to somehow equate modern medicine with Modern China, and Dr Sun Yat Sen the obvious effigy. Yet, where do all these lead to? Is the development of medicine set on an autogear along a rosy path? Are health care providers the more happier, the more freer in their pursuit of their duties?

In what is to follow, I would venture to bring you through my thoughts on how Modern Medicine help to build a Modern China, and the problems that it has brought. Similarly, whilst modernisation of a society must be a starting point for modern medicine, it too has its downside to the health care system and the health care providers. Such are global issues, for which China and Hong Kong are no exception.

Modern medicine help in building modern China

Few would doubt the value of modern medicine in the modernisation of China. The introduction of the concept of sanitation, the ridding of infectious diseases, the purification of drinking water, the essence of proper aeration and sunshine, the introduction of aseptic surgery, the introduction of antibiotics, the pathological basis of diseases and many many more have led to the annihilation of many human parasites, the diminishing of communicable diseases, the improvement of maternal and infantile mortality and morbidity and more so the extension of life expectancy. The rulers of China today are considered youngsters at the age of 70s whilst many former monarchs could have succumbed to consumption (tuberculosis) in their middle age.

"Headaches" brought by modern medicine

Examples abound both locally and overseas showing the effects of modern medicine in changing the society and yet the headaches that it could bring. When medicine was virtually non-existent, staying healthy, getting sick or perhaps dying was very much a matter of fact and a natural process. The individual man was responsible to himself from cradle to grave. The state or society basically had very little role nor could they play any role. The arrival of modern medicine promising a cure has not only raised the hope of the people, but the expectation that the society and state should provide, if not all, some of the care, and such are ever increasing. Today, in Hong Kong, for example, contracting cholera for ingesting infected shell fish, despite warning, is considered by the public as government's responsibility. The state is expected to foot the bill for removing unwanted self inflicted tattoo and corrective lasik surgery just because the individual thinks he/she looks more handsome without corrective lens.

Such over dependence of medicine, and the government to provide, call for an ever enlarging health care budget. In the United States, therefore, although some 14% of Gross Domestic Product (GDP) is spent on health, yet some over 20% of their population are next to devoid of proper health care.

It is no surprise that health care could well become a top priority political agenda not only for vote winning but to maintain a stabilised society. To wit, in 1992, one of the campaign issues securing Bill Clinton's election was his undertaking on health care reform although he dropped the issue after he became President (not uncommon with politicians); the National Health Scheme (NHS) has always been Margaret Thatcher's headache. Even in China, health care was one of the major areas of reform in the Ninth Five-Year Plan (1995-2000). Any slipped in health care direction today can thus topple a government.

Inflated expectations from public

Nor has modern medicine been kind to modern medicine. For as modern medicine promises a cure, it inflates expectation and foster insatiable hope, many modern medicine will hardly be able to fulfill. When modern medicine produces a cure for infectious disease, the public escalate to expect it to do wonders to chronic illnesses. When transplant surgery replaces a damaged organ by a properly functioning one, the populace demands a cure to maintain, if not improve, their power of memory and IQ. The finest hour of medicine is thus also the dawn of its dilemma. When medicine was impotent, it was unproblematic. Today when many "missions are accomplished" by modern medicine, its triumphs are dissolving in disorientation. Modern medicine has to redefine its limits even as it extends its capacity, and we, the health care workers, will have to bring this into existence!

In the early days of modern medicine, medicine itself used to be atomised, a jungle of patient-doctor transactions. Practitioners were self employed working with a small back up team of pharmacists and surgeon-apprentices pinning down a screaming amputee. Patient-doctor relations typically involved a personal contact, initiated by a sick person calling for a doctor.

Today, medicine has turned into proverbial industrialised medical complexes comparable to a military establishment or the civil service. Like it or not, the public is sucked into these institutions whether sick or otherwise in their quest for an expected health. A former chairman of a fast food chain in the US has quit to head a hospital corporation because he felt that the growth potential of health care setting would be unlimited, better than Kentuchy Fried Chicken. Such medicalisation of the society has thus resulted in medicine seemingly good for business and business good for medicine.

Impact on Chinese medicine

How have modern medicine and modern China affected its practitioners? For centuries, medical care in China fell into the sole realm of the TCM practitioners. Trainings were on an apprenticeship system and efficacy based on experience. No criteria existed to qualify one's suitability for becoming a TCM practitioner other than the blessing of his/her tutor. With societal modernisation came demand for accountability. Registration became a necessity to differentiate the real TCM practitioners from the quacks. This is taking place in Hong Kong and in the Mainland under the Medical Practitioners Ordinance (Yi Shi Fa).

A short while ago, I was commenting that TCM is not evidence based. This is in stark contradiction from modern medicine. And in a modern society, patients would always expect evidence based means of treatment when their lives are in the healer's hands. It is on this basis that modern training in TCM incorporated a lot of western medicine subjects notably anatomy and physiology, and the use of many modern diagnostic investigatory procedures.

In Hong Kong, as a Chinese community and under the direction of the Basic Law, TCM will not only stay but has to be developed. Like it or not, TCM will continue to be an element in the whole spectrum of health care. As such, we western-trained practitioners with experience in evidence base medicine would not be doing our duty for societal good if we refuse to take TCM on board, lead them along the pathway to evidence based medicine, retain what are efficacious and discard whatever quackery. There should never be any conflict between these two medical fronts. Instead, both should be considered, as complimentary.

Societal involvements of doctors

History has it that Dr Sun Yat Sen forwent his hard earned medical career for a more honourable job to heal the society. Yet if he were to remain as a medical man, his respect from the society would not be any less. Doctor's status socially and otherwise was high. For as the limited chosen few in those era to know the intricacy of human anatomy and physiology, saving life and sustaining health for prince to pauper anything they say must be taken as "gospel truth" and with complete adoration.

Yet as the public become more knowledgeable from Times magazine and Reader's Digest, as the world gets smaller through the internet, as the society becomes more modern and thus assertion of their rights, the knowledge and societal superiority of the medical profession are put on trial and challenge. Overnight the days when "doctors are demigods" are over and it so should be.

Stirred by wider consumer protection and rights movement, the "sick" learned to abandon the role of a "child" accepting medicine from a paternalistic doctor. They began to assume the guise of "adults". The importance of informed consent and other ethical desiderata underlined. The mute deference so characteristic of previous generations - the assumption among doctors that patients did not want to know what's wrong with them and they could not possible understand - was challenged.

In Hong Kong, such process has taken on in a very abrupt way. Geared by the imminent change of sovereignty, in preparation for "Hong Kong people ruling Hong Kong", the then colonial government introduced hastily the formula of representative government. Rights and power of the vote were given to the former apolitical and obedient public. Human rights and patients rights are high on the agenda. The doctors, like our civil servants, are put on the microscopes and their actions must not only be transparent but fully accounted for, and so it should be.

Influences of democratisation

The whole transformation, perhaps the concept of modernisation, though a natural process in the evolution of democracy, was complicated in Hong Kong by confusion of the future, suspicion of communist rule and the lack of confidence in the change of sovereignty. The society became divided into "the haves and the have nots"; "the Government and the public"; "the grassroots and the establishment".

For whatever reason, doctors are somehow classified as part of the "establishment". We are also labelled as the "haves". Overnight, the doctors lose their trust. Overnight, our superiority is denigrated, our usually unchallengeable positions are shaken. Overnight, the overdogs become the underdogs. We have been unreasonably criticised for our effort in spite of our continuous strive for public good. This is too much for the medical profession to accept. Our self esteem is crushed! The media and critics take every opportunity to jump onto the bandwagon. The current "mobile phone saga" is very much a storm in the teacup though the handling of the situation by the Medical Council cannot be completely absolved from blame. Even a Coroner a few days ago caught the public mood and criticised severely not only the doctor concerned for perforating an oesophagus while performing an oesophagoscopy, but the whole profession. Something seldom seen in the past.

Hong Kong has sailed through a political transition. The medical profession is to face yet another transition of no less magnitude.

Ladies and Gentlemen, what can we do? How can we react to lift the gloom? How can we regain loss ground?

Keeping abreast of medical advances

Let us not forget: whether it is in the days of Sun Yat Sen or the future, people will still be sick; new diseases will still be discovered. The health care professionals will always be needed to care for those that are ill. The medical profession will always have to take the lead of the health care team to master new technologies to provide yet further chances of cure for those in suffering. This is where we must begin.

Through the various constituent Colleges of the Hong Kong Academy of Medicine, we must keep abreast with medical sciences to give whatever little better we can offer to our patients.

On this basis, the Academy is bestowed with a unique situation. Dealing only with medical standards and approving only standards of the highest grade, the Academy must be seen as above board, away from political bickering, away from defending doctors' rights. Instead, we are seen as the body to give the public the best of health through training, vetting and insisting that doctors are always above par.

Yet the Academy can do these only through workable Continuing Medical Education / Continuous Professional Development programmes, and through demonstrating to the public that every Fellow have to pass through quality assurance criteria.

The Academy and our Colleges have to take up the role of continuing with our international relationship to ensure that our medical standards are universally acceptable and reciprocal. But there is more. We have to try our best to enhance our international connections, through active participation in regional and international conferences, take a positive role and be involved in medical regional and international bodies. For as the rest of China improves its medical standards, and it will, the only edge Hong Kong has over them is our international medical relationship. Let the flag of Hong Kong be seen in all international medical organisations.

The Basic Law has given us the autonomy to participate in the world's medical bodies in our own right. Let us capture on this and retain it to our best interest. It will be hard work for our medical leaders to be always on the go, carry the Special Administrative Region flag and fly it, but it must be done for future good!

Leading and participating in societal affairs

Finally the doctors and dentists in Hong Kong must participate more in the society. Medical problems, societal problems and ethical problems are no more clear-cut. The decision on reproductive technology and transplantation surgery for example cross many disciplines and cannot be solved with hard medical knowhow alone. The doctors and dentists of modern China must learn more of the society at large to influence the society.

Talking about influence, the medical practitioners have a distinct advantage. Our patients come from all sectors of the society - from billionaires to those on the dole. They basically trust us as they have pledged their lives in our hands.

We have to speak out for the profession and for the society. We must take part in the different tiers of Government engaged in elections not only to provide our unbiased input, professional expertise but also as patients and society's advocates. For if we believe that the disharmony of the society is the root of all diseases, then we as healers of individuals cannot refrain from extending our role to heal the society. Helping the society will invariably result in helping ourselves.

There will be those of you who will ask "why me, why us?" Let us not ask why; but ask why not. Many of us in our ranks have done this. Our Professor of Surgery in the Chinese University has given up his cutting expertise to run the whole university. Our popular dentist and dental teacher at the Prince Philip Dental Hospital has relinquished the art of pulling teeth to nurture The University of Hong Kong. Our hepatitis and AIDS consultant physician has forgone his first love in medicine to take up a much lower remunerated job to formulate medical policies for Hong Kong. But we need more.

Yes, all these mean changes in our basic instinct and culture as a doctor and a dentist, perhaps even a change at how the society will perceive us as medical and dental practitioners. But let us create a change if a change is for the better and let us not wait to react to change.

Cure physical and societal ailments

Mr President, Ladies and Gentlemen, no country or region can do without good medical and health care, for maintaining health and curing diseases must be the hub of any societies and social stability. In the same light, modernisation of China and modernisation of medicine in China are integral parts. They are intertwining and cannot be separated. It is here that we as doctors and dentists have to take an active role.

John Keats, an English poet, wrote in the poem "On His Blindness" said: "They also serve, those who only stand and wait."There is no room for doctors and dentists to "just stand and wait". We need to be not only good doctors, but good statesmen (既為良醫，亦為良相) to make modern China tick.

Let me end by quoting from Nei Jing (內經/ Inner Canon) (perhaps the oldest ancient literature on TCM) as a message to the new Fellows of the esteemed Hong Kong College of Family Physicians:

"The superior doctors heal the country. The good doctors heal the people. The ordinary doctors treat the diseases." "上醫醫國，中醫醫人，下醫醫病。"