Elder Care by Remote - BusinessWeek

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By Arlene Weintraub

For three months early this year, 63-year-old Ronald Lang was one of the most plugged-in patients in America. Lang, who suffers from congestive heart failure and multiple sclerosis, was pilot-testing the Intel (INTC) Health Guide, a device that lets doctors monitor his health remotely. Each day after he woke up, he'd step on a scale and strap on a blood pressure cuff that was attached to the Health Guide. The device collected his vital signs and zapped them to his doctor's office. From there, Nurse Marie DiCola scoured the data, and if she noticed anything amiss, she dialed Lang and chatted with him over Health Guide's videophone.

Health Guide is at the leading edge of a new technology trend called "aging in place," designed to help seniors stay longer where they're most comfortable—at home—rather than having to move into nursing or assisted-living facilities. Aging-in-place equipment is installed in a person's home, monitors symptoms on the spot, and sends reports to doctors or family members in real time.

As 77 million baby boomers race toward their golden years, the world's leading tech innovators are unveiling a range of futuristic gizmos. There are beds that can monitor patients' vital signs as they sleep and stoves that can turn themselves off when owners forget. Besides Intel, the aging-in-place market has attracted companies such as General Electric (GE), Philips Electronics (PHG), Honeywell (HON), Bosch, and dozens of tech startups. The companies say these products, just now being deployed by a handful of health plans and home-care agencies, can drastically cut the rate of medical complications that force seniors into hospitals and other intensive-care facilities.

Health Guide epitomizes the kind of in-home gear that can reduce the hassle factor for patients and clinicians, especially those dealing with chronic but easy-to-monitor diseases. Heart failure patients, for example, must measure their weight and blood pressure frequently because changes in either metric can signal the type of trouble that requires emergency intervention. But distinguishing between a minor setback and a serious situation depends on being able to figure out how the patient is feeling.

In the program Lang was a part of, Nurse DiCola was able to assess symptoms both by talking to patients and examining them visually. She downloaded real-time data for as many as 25 patients every day and spoke to many using Health Guide's videophone. "I could make decisions about treatment," she says. "If they needed to see the doctor, I got them in to see a cardiologist right away." For Lang, desktop access to DiCola was comforting. "I used to have to get dressed, go to the doctor's office, wait, and pay my $10—just for them to take my blood pressure," Lang says. "Then the doctor would say: 'Everything is fine. Take your medicine.'"

Executives at Intel envision a suite of products that can give any house the characteristics of an assisted-living facility, but without the sterile environment many seniors despise. A survey taken late last year by AARP revealed that nearly 80% of baby boomers expect to stay in their homes as they age.

Intel has enlisted a big ally to help position itself in this market. In April, Intel and General Electric announced they would spend $250 million over five years to co-develop products that will help seniors manage chronic conditions from home. As part of the deal, GE will sell the Intel Health Guide. The partnership will give Intel access to monitoring technology, which ultimately could enhance Health Guide's capabilities. GE already has a product, QuietCare, which uses sensors stationed throughout the home to keep an eye on seniors as they go about their day-to-day lives. GE is marketing the product through home health-care companies and to assisted-living facilities. For an individual who wants the system at home, it's not cheap—the cost would be about $70 to $110 per month, depending on the size of the unit and the length of the monitoring agreement.

Amsterdam-based Royal Philips Electronics is also focusing on the aging-in-place market. Since 2006 it has spent $6 billion snapping up home health-care companies, including Lifeline, a maker of personal emergency alert systems that cost subscribers from $35 to $75 per month. Philips also purchased breathing device maker Respironics, as well as Raytel Cardiac Services, a provider of remote cardiac monitoring services. And recently Philips developed the smartBed, which contains tiny, high-tech electronic sensors that can measure patients' vital signs, movement, and breathing as they sleep. (The product is part of a research project and not commercially available.)

As helpful as aging-in-place technology may be, there is one big question yet to be answered: Who is going to pay to put the systems into seniors' homes? "Right now this is a niche market made up of affluent people who want to monitor their parents," says Scott Lundstrom, vice-president for research at IDC Health Insights. "The technology is going nowhere without a reimbursement model that supports it."

Intel and others are trying to convince public and private insurers that it is an investment worth making. During a road show to launch Health Guide, Intel referred to a study published by the Veterans Administration late last year. It found that remote patient monitoring decreased hospital visits significantly—for instance, 20% for diabetes patients and 56% for patients with depression. The technology cost $1,600 per patient per year on average, it reported, as opposed to $77,745 for nursing home care. Intel says it's currently talking with health-care organizations that may provide the full package of service and support directly to consumers. It is also evaluating monthly service programs.

Intel has pilot-tested Health Guide with Aetna and other insurance companies. Lang, who lives in Cypress, Calif., was part of a test conducted by SCAN Health, a nonprofit health plan in California and Arizona. "It became obvious, as we looked at the growth of the aging population and the number of caregivers we had, that relying on an entirely people-based model would be untenable," says Hank Osowski, senior vice-president for corporate development at SCAN. Osowski isn't ready to commit to any specific system, but says remote monitoring will be part of SCAN's model. "We're willing to fund these tools," he says, "because at the end of the day it will result in better [patient] outcomes."

For Abortion Foes, a Victory in Health Care Vote - NYTimes.com

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By DAVID D. KIRKPATRICK and ROBERT PEAR

WASHINGTON — A restriction on abortion coverage, added late Saturday to the health care bill passed by the House, has energized abortion opponents with their biggest victory in years — emboldening them for a pitched battle in the Senate.

The provision would block the use of federal subsidies for insurance that covers elective abortions. Advocates on both sides are calling Saturday’s vote the biggest turning point in the battle over the procedure since the ban on so-called partial birth abortions six years ago.

Both sides credited a forceful lobbying effort by Roman Catholic bishops with the success of the provision, inserted in the bill under pressure from conservative Democrats.

The provision would apply only to insurance policies purchased with the federal subsidies that the health legislation would create to help low- and middle-income people, and to policies sold by a government-run insurance plan that would be created by the legislation.

Abortion rights advocates charged Sunday that the provision threatened to deprive women of abortion coverage because insurers would drop the procedure from their plans in order to sell them in the newly expanded market of people receiving subsidies. The subsidized market would be large because anyone earning less than $88,000 for a family of four — four times the poverty level — would be eligible for a subsidy under the House bill. Women who received subsidies or public insurance could still pay out of pocket for the procedure. Or they could buy separate insurance riders to cover abortion, though some evidence suggests few would, in part because unwanted pregnancies are by their nature unexpected.

Not many women who undergo abortions file private insurance claims, perhaps to avoid leaving a record. A 2003 study by the Alan Guttmacher Institute found that 13 percent of abortions were billed directly to insurance companies. Only about half of those who receive insurance coverage from their employers have coverage of abortion in any event, according to a study by the Kaiser Family Foundation.

Abortion rights advocates, however, are grappling with a series of incremental defeats in the courts and in Congress, and are now bracing for another struggle as the health care legislation goes to the Senate.

“This is going to make it that much more challenging on the Senate side,” said Nancy Keenan, president of Naral Pro-Choice America.

The president and Democratic leaders alike have long promised that their proposed health care overhaul would not direct taxpayer money to pay for elective abortions. But the president has never spelled out his answer to the contentious question of how to apply that standard to the novel program of offering insurance subsidies or a government-run plan to millions of poor and middle-class Americans.

House Democratic leaders had sought to resolve the issue by requiring insurers to segregate their federal subsidies into separate accounts.

Insurance plans would have been permitted to use only consumer premiums or co-payments to pay for abortions, even if individuals who received federal subsidies used them to buy health plans that covered abortion. But the House speaker, Nancy Pelosi, was unable to hold on to enough moderate and conservative Democratic votes to pass the health bill using that approach, forcing her to allow a vote Saturday night on the amendment containing the broader ban.

Five states go further than the amendment to the health care overhaul. The five — Idaho, Kentucky, Missouri, North Dakota and Oklahoma — already bar private insurance plans from covering elective abortions.

The federal employees’ health insurance plan and most state Medicaid programs also ban coverage of abortion, complying with a three-decade old ban on federal abortion financing. Seventeen state Medicaid programs, however, do cover the procedure, by using only state money.

The bishops objected to the segregated funds proposal previously embraced by the House and Senate Democratic leaders in part because they argued that it amounted to nothing more than an accounting gimmick.

Advocates on both sides of the question weighed in, but the bishops’ role was especially pivotal in part because many Democrats had expected them to be an ally. They had pushed for decades for universal health insurance.

“We think that providing health care is itself a pro-life thing, and we think that, by and large, providing better health coverage to women could reduce abortions,” said Richard M. Doerflinger, a spokesman for the anti-abortion division of the United States Conference of Catholic Bishops.

“But we don’t make these decisions statistically, and to get to that good we cannot do something seriously evil.”

Beginning in late July, the bishops began issuing a series of increasingly stern letters to lawmakers making clear that they saw the abortion-financing issue as pre-eminent, a deal-breaker.

At the funeral of Senator Edward M. Kennedy in August, Cardinal Seán O’Malley, the archbishop of Boston, stole a private moment with Mr. Obama to deliver the same warning: The bishops very much wanted to support his health care overhaul but not if it provided for abortions. The president “listened intently,” the cardinal reported on his blog.

Bishops implored their priests and parishioners to call lawmakers. Conservative Democrats negotiating over the issue with party leaders often expressed their desire to meet the bishops’ criteria, according to many people involved in the talks. On Oct. 8 three members of the bishops conference wrote on its behalf to lawmakers, “If the final legislation does not meet our principles, we will have no choice but to oppose the bill.”

On Sunday, some abortion rights advocates lashed out at the bishops. “It was an unconscionable power play,” said Cecile Richards, president of Planned Parenthood Federation of America, accusing the bishops of “interceding to put their own ideology in the national health care plan.”

Now some Senate Democrats, including Bob Casey of Pennsylvania and Ben Nelson of Nebraska, are pushing to incorporate the same restrictions in their own bill. Senior Senate Democratic aides said the outcome was too close to call.

Flu outrunning vaccine, experts say - washingtonpost.com

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Shots may not be widely available until December or January

By David Brown
Washington Post Staff Writer
Thursday, November 5, 2009

Two state and city public health officials briefing Congress on Wednesday said they don't expect to have enough pandemic-flu vaccine to meet the needs of their high-priority population groups until well into December, and possibly not until January.

The officials said that their predictions are a result of maddening vaccine shortages throughout the fall but that they amount to little more than guesses.

Federal health officials at the same briefing refused to endorse the gloomy timetable -- or any other one -- although they acknowledged that the current wave of H1N1 influenza may be mostly over by the time the vaccine is abundant.

"Current projections show that 62 percent of Alabama's vaccine will not be available until after December 1," Donald E. Williamson, the state's health officer, told a House Appropriations subcommittee. Offering flu shots to people outside the five priority recipient groups "may not be possible until late December or January."

The director of the public health department in St. Paul, Minn., said he thinks it will be "sometime between Christmas and mid-January" before there is enough vaccine to fully immunize the high-risk groups -- pregnant women, health workers, parents caring for newborns, people 6 months through 24 years old and chronically ill people ages 25 through 64.

"I don't think we'll have enough before then," said Rob Fulton, adding that what's true for St. Paul is probably true for all of Minnesota.

The federal government has ordered 250 million doses of pandemic H1N1 influenza vaccine. It has said that will be more than enough to satisfy demand among the country's 308 million residents. The high-priority groups include 159 million people.

As of this week, 32.3 million doses of pandemic vaccine had been made available to states and cities by the federal government, which is controlling the entire U.S. supply.

Members of the House Appropriations subcommittee on Labor, Health and Human Services, Education and Related Agencies repeatedly queried the federal officials about timelines for future supplies. While five weeks ago they were still predicting that there would be more than 100 million doses by now, none of the officials would hazard a guess.

"We have been working extremely hard with each manufacturer to make sure all of the stumbling blocks are out of the way," Nicole Lurie, assistant secretary for preparedness and response at the Department of Health and Human Services, told Rep. David R. Obey (D-Wis.), chairman of the subcommittee. "Flu is really unpredictable. We're pretty hesitant about projecting ahead more than week to week."

Thomas R. Frieden, director of the Centers for Disease Control and Prevention, also declined to look ahead, saying, "We have been burned, quite frankly, by predictions that have not come to pass." Under later questioning, he did say that "it is quite likely that the current wave of influenza will peak, crest and begin to decline before there are ample supplies" of vaccine.

Pandemic influenza -- defined as a highly contagious strain to which virtually everyone in the world is susceptible -- tends to move through populations in waves, sometimes over several years. For example, the Asian flu of 1957, which bears many similarities to the current pandemic, was responsible for about 60,000 "excess deaths" in the United States. About 40,000 occurred in the summer and fall of 1957, and 20,000 in the late winter and early spring of 1958.

The chief reason there is so little flu vaccine is that the novel H1N1 grows slowly in fertilized chicken eggs, the medium where it is made in industrial quantities.

Normally, vaccine-makers expect to get two to three doses of vaccine out of each egg injected. At the start of production in the summer, the yield was 0.2 to 0.5 doses per egg, said Robin Robinson, director of the Biomedical Advanced Research and Development Authority, which is part of HHS. After tinkering with growth conditions and other variables, it is now 1.3 to 2 doses per egg.

"If we had been getting 2.5 doses per egg [throughout the summer and fall], we wouldn't be having this hearing now," he said.

The vaccine shortage is the consequence of the virus's biology, not human laziness or incompetence, the officials told the lawmakers many times.

"I don't want people to get the impression that it is the drug companies' fault in not getting this delivered," said Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases.

Government officials have asked the four makers of injectable vaccine to put most of their current production into multi-dose vials, which can be filled about five times more quickly than single-dose vials or pre-filled syringes and may save a little time.

How to prevent getting swine flu and what to do if you have it - washingtonpost.com

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Sunday, November 1, 2009

Andrew Pekosz, an associate professor of molecular microbiology and immunology at Johns Hopkins University's Bloomberg School of Public Health in Baltimore, answers questions about H1N1 swine flu.

How can I tell if I have swine flu? And does it matter if it's that flu or the seasonal one?

Virtually all the cases of influenza occurring at this time are caused by 2009 H1N1. While individuals with severe flu-like illness are being tested to determine for certain which virus is causing the disease, there is no need for most people to get tested.

How do I know if I or someone in my family should go to the hospital?

Some key symptoms to watch for include rapid but shallow breathing, difficulty in breathing and lethargy or extreme weakness. A complete list of symptoms can be found at http://www.cdc.gov/h1n1flu/sick.htm#3.

What is the best source of information about the H1N1 virus?

There are couple of Web sites that provide good general information on the H1N1 virus; the one I like for information to the general public is http://www.flu.gov, but be sure to check with your state or county public health department.

Who should get vaccinated? What are the priority groups?

There are several priority groups being targeted for vaccination while the vaccine is in short supply. The complete list is at http://www.flu.gov/individualfamily/vaccination/vprioritygroups.html but includes pregnant women, health-care and emergency medical personnel, household contacts or caregivers of children under the age of 6 months, anyone between the ages of 6 months and 24 years of age, and people age 25 to 64 who have underlying medical conditions.

What's the difference between nasal spray and injection? Who should get what kind?

The nasal-spray vaccine is a weakened form of the virus that does not cause influenza but does generate a good immune response. The injectable vaccine is an inactivated or "killed" form of the virus which is injected into the muscle of your arm. The nasal spray is only available to healthy individuals age 2 to 49, while the injectable vaccine is available to a wider range of the population. More information is available at http://www.cdc.gov/h1n1flu/vaccination/general.htm.

If I can't get the vaccine right away, is it still worth getting it later?

Yes. . . . We are not certain how long the flu season will last, or if we will have several flu seasons or "waves" this year, so when vaccine becomes available, everyone should take advantage of it.

How quickly does the vaccination take effect? Is it possible to come down with the flu soon after getting vaccinated?

After three weeks, most people have an immune response that will protect them from infection with 2009 H1N1. The immune response begins to be detected seven to seven to 10 days after vaccination. The vaccines cannot cause the flu, but you certainly could catch influenza during the time after vaccination when your body hasn't developed a strong anti-influenza immune response.

Should everyone who comes down with the flu take Tamiflu or Relenza?

No. The CDC guidelines recommend that only individuals who are in high-risk groups should receive Tamiflu or Relenza at the first sign of symptoms. If you develop symptoms of severe influenza, then you should seek out medical treatment and begin to take Tamiflu and Relenza. For most people who will come down with the mild form of the disease, the use of Tamiflu or Relenza is not recommended in order to ensure enough of the drugs are available.

Obama Declares Swine Flu Outbreak a National Emergency - NYTimes.com

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By JACKIE CALMES and DONALD G. McNEIL Jr.

WASHINGTON — President Obama has declared the swine flu outbreak a national emergency, allowing hospitals and local governments to speedily set up alternate sites for treatment and triage procedures if needed to handle any surge of patients, the White House said on Saturday.

The declaration came as thousands of people lined up in cities across the country to receive vaccinations, and as federal officials acknowledged that their ambitious vaccination program has gotten off to a slow start. Only 16 million doses of the vaccine were available now, and about 30 million were expected by the end of the month. Some states have requested 10 times the amount they have been allotted.

Flu activity — virtually all of it the swine flu — is now widespread in 46 states, a level that federal officials say equals the peak of a typical winter flu season. Millions of people in the United States have had swine flu, known as H1N1, either in the first wave in the spring or the current wave.

Although there has been no exact count, officials said the H1N1 virus has killed more than 1,000 Americans and hospitalized over 20,000. The emergency declaration, which Mr. Obama signed Friday night, has to do only with hospital treatment, not with the vaccine. Government officials emphasized that Mr. Obama’s declaration was largely an administrative move that did not signify any unanticipated worsening of the outbreak of the H1N1 flu nationwide. Nor, they said, did it have anything to do with the reports of vaccine shortages.

“This is not a response to any new developments,” said Reid Cherlin, a White House spokesman. “It’s an important tool in our kit going forward.”

Mr. Obama’s declaration was necessary to empower Kathleen Sebelius, the secretary of Health and Human Services, to issue waivers that allow hospitals in danger of being overwhelmed with swine flu patients to execute disaster operation plans that include transferring patients off-site to satellite facilities or other hospitals.

The department first declared a public health emergency in April; Ms. Sebelius renewed it on Tuesday. But the separate presidential declaration was required to waive federal laws put in place to protect patients’ privacy and to ensure that they are not discriminated against based on their source of payment for care, including Medicare, Medicaid and the states’ Children’s Health Insurance Program.

As a practical matter, officials said, the waiver could allow a hospital to set up a make-shift satellite facility for swine flu patients in a local armory or other suitably spacious location, or at another hospital, to segregate such cases for treatment. Under federal law, if the patients are sent off site without a waiver, the hospital could be refused reimbursement for care as a sanction.

A few hospitals, including some in Texas and Tennessee, have set up triage tents in their parking lots to screen patients with fever or other flu symptoms. A Health and Human Services official said no hospitals had requested a waiver. David Daigle of the Centers for Disease Control and Prevention said he had not heard of any hospital that has faced a surge of patients so large that it had to set up a triage area or a treatment unit off site.

In Chicago on Saturday, health officials began giving free vaccinations at six City College locations, and within hours hundreds of people were turned away because supplies had been exhausted. The city distributed 1,200 vaccines to each site, immunizing more than 7,000 people, said Tim Hadac, spokesman for the Chicago Department of Public Health. All but two of the sites ran out of the vaccine.

At Truman College on Chicago’s North Side, lines formed at 7 a.m., two hours before the doors opened. Mary Kate Merna, 28, a teacher who is nine months pregnant, arrived too late to get a vaccination. “I thought I’d be a priority being nine months pregnant,” she said. “You hear it’s a national emergency and it scares you.”

In Fairfax County, Va., officials had planned to have swine flu clinics at 10 different locations on Saturday. But the county did not receive the number of doses it requested, and was forced to offer the vaccinations only at the government building. People began lining up with camping gear the night before to get vaccinations.

Merni Fitzgerald, Fairfax’s public affairs director, said officials were aiming to administer 12,000 doses of the vaccine to those most at risk for serious complications from the H1N1 virus, mainly pregnant women and children 6 to 36 months.

But that did not stop some other high-risk patients. “I lied and told the doctors I was pregnant,” said Theresa Caffey of Centreville, who has multiple sclerosis and nurses her 11-week-old son, Joshua. “I’m religious. I don’t lie. But it’s not about me. It’s for my son. It’s safer for him if I have the antibodies.”

In a briefing on Friday, Dr. Thomas Frieden, the C.D.C. director, acknowledged problems with the vaccine production. “We share the frustration of people who have waited on line or called a number or checked a Web site and haven’t been able to find a place to get vaccinated,” he said.

Federal officials predicted last spring that as many as 120 million doses could be available by now, with nearly 200 million by year’s end. But production problems plagued some of the five companies contracted to make the vaccine. All use a technology involving growing the vaccine in fertilized chicken eggs; at most of them, the seed strain grew more slowly than expected.

The manufacturers are “working hard to get vaccine out as safely and rapidly as possible,” Dr. Frieden said. But since it is grown in eggs, “even if you yell at them, they don’t grow faster.”

Since last winter’s more isolated cases of swine flu, the expectation that the virus would return with a vengeance in this flu season had posed a test of the Obama administration’s preparedness. Officials are mindful that the previous administration’s failure to better prepare for and respond to Hurricane Katrina in 2005 left doubts that dogged President George W. Bush to the end of his term.

There is no overall shortage of seasonal flu vaccine — 85 million doses have shipped, and the season has not started. But there are temporary local shortages. The seasonal flu typically hospitalizes 200,000 and kills 36,000 nationwide each year. But over 90 percent of the deaths are among the elderly, while the swine flu mostly affects the young.

Jackie Calmes reported from Washington, and Donald G. McNeil Jr. from New York. Crystal Yednak in Chicago and Holli Chmela in Fairfax, Va. contributed reporting.

In China, Rx for Ailing Health System - WSJ.com

By GORDON FAIRCLOUGH

AFP/Getty

Employees at a community health center in Shanghai stand ready for patients.

QUNGUANG, China -- Here in China's agricultural heartland, signs of progress abound. Qunguang village's 1,000 inhabitants, who live among rolling fields of corn, rice and peanuts, are linked to the world by a new 215-mile, $1.6 billion expressway. An industrial park is under construction nearby. Incomes for rural people in the county jumped 85% between 2000 and 2008.

At the local health clinic, not far from the highway exit ramp, Mei Ruying diagnoses patients with little more than a stethoscope and a thermometer. To keep abreast of new drugs, Ms. Mei, who lacks a medical degree, reads instructions enclosed in the boxes.

China's rickety health-care system relies on thousands of practitioners like Ms. Mei. Often, they are poorly compensated and ill-equipped to serve their big rural constituencies. According to the national health ministry, just 17% of China's medical workers in 2005 were university graduates. In village clinics and township hospitals, just 2% were.

The Long March: The Revolution at 60

• Complete Coverage: The Long March

As China continues riding a long wave of prosperity, its health-care woes are under a spotlight. Medical treatment has improved greatly for many Chinese in recent times of heady growth. But the system of near-universal but basic coverage offered in the years after the Communist revolution has frayed. Opinion polls rank medical care among citizens' top concerns. Spiraling drug costs, inadequate insurance and big out-of-pocket expenses are all cause for public distress. In poor rural areas, many forgo treatment because they can't afford it.

Now, as the Communist Party leadership this month celebrates its 60th year in power, it is moving away from a nearly single-minded focus on economic growth that shaped policy for much of the past three decades.

This year, the government announced a plan to spend more than $120 billion on the first phase of a 10-year overhaul of the health-care system. By 2020, China says, it wants all its citizens to have access to affordable, basic medical services.

"The public is demanding this," says Mao Qunan, spokesman of the Ministry of Health. "Investment in health-care has not kept up," he says, and the new approach is meant to bring the country's health system "in line with China's economic and social development."

The government is renovating thousands of medical facilities and funding broader state-sponsored insurance coverage. After a recent push, the government says that about 77% of people are enrolled in insurance plans, though the portion of medical expenses covered is often relatively low. About 300 million people have no coverage at all.

Just as health-care reform in the U.S. is testing the Obama administration, China's medical policy has become a political lightning rod for China's president, Hu Jintao. Mr. Hu and other top officials have pledged to "put people first" and to pursue a more balanced approach to economic development than their predecessors.

William Hsiao, a Harvard University health economist who has studied Chinese health care for years, says previous Chinese leaders were deeply skeptical about the benefits of investing in health. The attitude, he says, was: "There's a surplus of labor. So, more people die prematurely. It doesn't affect the labor market materially."

Now, he says, President Hu and other top leaders -- who spent much of their careers working in rural areas -- have a better understanding of the troubles facing the country's rural poor. "They worry that unhappiness at the grass-roots level could result in social unrest. There is that sense of threat," he says.

In 2006, the latest year for which the government has released figures, nearly 10,000 incidents of violent protest were spurred by people unhappy with the care, or lack of it, provided by state hospitals.

In a speech last month, Li Keqiang, China's vice premier, said that repairing the health-care system would have "an overall impact on reform, development and stability" in China.

Chinese health-care reform could also play a role in making the economy less reliant on exports by stimulating domestic demand.

The specter of high medical costs -- and the lack of a social-security system -- is a major force driving Chinese to save rather than spend.

Whether China succeeds in the task has implications for global public health. China is the world's most-populous nation, with 1.3 billion people. And diseases that emerge here -- such as severe acute respiratory syndrome -- quickly spread around the world.

Officials are handicapped by years of underspending. Government outlays for health care amounted to less than 1% of gross domestic product in 2006, ranking China No. 156 out of 196 nations surveyed by the World Health Organization.

The $124 billion infusion, promised through 2011, will provide a substantial boost. But it is only a start. And the tab could be higher than expected: Chronic illnesses -- such as heart disease, high blood pressure and diabetes -- are becoming more prevalent as China grows affluent.

In the first decades of Communist rule, China made significant public-health strides. Initiatives reduced malaria deaths and infant mortality rates. Workers on collective farms and in state-run factories received almost universal, if very basic, medical care.

That system started to unravel in the late 1970s as China began to embrace capitalist-market economics. Rural communes were disbanded and inefficient state enterprises went bust. Funding for public hospitals and clinics slowed. Out-of-pocket payments for medical services rose from 20% of health-care expenditures in 1978 to roughly 50% in 2006, according to government figures.

A central goal of Beijing is to improve the affordability and availability of care in China's less well-off rural areas, which are home to more than half the population. To do that, the government has launched a crash construction program for county hospitals and township clinics. And it is pouring more money into a rural-cooperative health-insurance program.

One beneficiary of the new funds is the Ninghe County Hospital, located in a farming area outside the northeastern port city of Tianjin. Using government cash, the hospital was able to complete an 11-story surgical in-patient building, more than doubling its capacity, to 800 beds from 350.

The new facility boasts nine operating rooms, a 15-bed intensive-care unit and a kidney-dialysis ward equipped with state-of-the-art blood-filtering equipment from Germany. The hospital also has two CT scanners and two MRIs.

"We are responding to the call of the government to help farmers with better health-care services," says Meng Qinghai, the hospital's deputy director. "Our goal is to provide a U.S. standard of modern medicine."

One problem, analysts say, is that few of China's rural poor can afford such high-tech offerings.

The government has been ratcheting up the insurance coverage available to farmers through county-level rural-cooperative insurance plans. The programs, which began in 2003, now cover roughly 90% of rural people, according to the health ministry.

So far, coverage remains limited. Most out-patient services and medicines aren't included in the plans at all. Bills for hospitalization are available for reimbursement at varying rates, which are different from county to county. The health ministry says its goal is 50% reimbursement for hospital stays by next year.

"Fifty percent may not seem like that much for Americans or British people. But for Chinese farmers, it's a very big milestone," says Mr. Mao, the health ministry spokesman.

Compared to having no coverage, which was common for rural Chinese as recently as a few years ago, it is a vast improvement. In Jingshan county, home to Qunguang, about 93% of people were enrolled in the cooperative insurance plan in 2008, up from 85% the year before.

"Now that there's insurance, people come to see doctors. Before they were too poor," says Zhu Zhongnian, a surgeon the Jingshan county hospital. "It's a very good thing for ordinary people." But with the high cost of medical care, the coverage offered by the cooperative insurance still leaves many vulnerable.

Ma Deqing, a farmer here in Hubei's Qunguang village is a case in point. Mr. Ma, 67 years old, was diagnosed in the spring with cancer of the esophagus, the tube connecting the mouth and stomach, after a spell of vomiting and being unable to eat. He spent 44 days in the hospital before being discharged in July.

His medical bills totaled 25,000 yuan, or about $3,600 -- more than three times his family's annual income growing rice, peanuts and cotton. Mr. Ma had to pay the whole amount up front before his plan paid benefits, of about $1,000.

Mr. Ma, who lives with his wife, son, daughter-in-law and 7-year-old grandson, said his family used to be well-off by local standards. But it took the family's entire savings, gathered over years, to pay his medical bills. "If I need more treatment, I don't know what I'll do," he says.

Another problem with rural insurance, administered county by county, is that benefits aren't always portable. A worker who might have had coverage in one area but migrated to another could be out of luck. People who aren't registered residents of a county may be shut out of benefits, even if they pay premiums.

Zhang Jianfang has been renting farmland near Qunguang for years, growing corn, peanuts and cotton on a plot far from his hometown in the neighboring province of Henan. Mr. Zhang bought insurance through the local rural-cooperative plan for himself and his family. But when he had a motorcycle accident last year, the hospital told him he wouldn't be covered because his household registration was in Henan.

Local doctors said surgery to repair his broken collarbone would cost 10,000 yuan, or $1,400. Hoping to save money, he took a 24-hour train trip back to Henan, gritting his teeth against the pain and trying not to jostle his right arm. Surgeons there repaired the fracture with a steel plate for 3,000 yuan. But they wouldn't take his insurance, he says, since it was from Hubei province.

The government says that over time, it intends to increase benefits in order to reduce out-of-pocket expenses. And it is working on ways to ensure that people traveling or living outside their home counties will be covered in the event of illness or accident.

China's grass-roots medical personnel pose a different set of challenges. Driven in part by a fee-for-service model and a lack of sound treatment guidelines, they routinely overuse antibiotics and antiviral drugs, international public-health experts say. They prescribe them for patients with colds and flus -- a practice that could help spawn a new generation of drug-resistant pathogens.

The government is supporting continuing-education programs for rural practitioners and financing efforts to send more university-trained doctors to poor rural areas. Tuition assistance, for example, will be offered to medical students who pledge to spend a certain number of years working in the countryside.

In Qunguang, Ms. Mei's clinic income comes from fees for giving injections and the 15% markup she is allowed to charge for dispensing medicines. Still, she says, her medical work doesn't earn enough to support her. "If I didn't do farming, I couldn't even feed myself," says Ms. Mei, who, along with her husband, grows rice on a small plot.

Ms. Mei, who was a midwife before being selected to become a village doctor, passed an equivalence exam for a technical-high-school diploma in the 1990s. She says she thinks that is enough for her to do her job.

"It's complicated. We need a lot of medical knowledge," says Ms. Mei. "But you learn through experience."

—Ellen Zhu contributed to this article.

Write to Gordon Fairclough at gordon.fairclough@wsj.com

General health in Timor-Leste: self-assessed health in a large household survey

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Australian and New Zealand Journal of Public Health

Volume 33 Issue 4, Pages 378 - 383

Published Online: 4 Aug 2009

Jaya Earnest ¹ Robert P. Finger ²

¹ Centre for International Health, Curtin University of Technology, Western Australia ² Centre for International Health, Curtin University of Technology, Perth and Department of Ophthalmology, Bonn University, Bonn, Germany

Correspondence to:
Dr Jaya Earnest, Associate Professor and Postgraduate Research Co-ordinator, Centre for International Health, Curtin University of technology, GPO Box U1987, Perth WA, 6845. Fax: (08) 9266 2608; e-mail: J.Earnest@curtin.edu.au

Copyright © 2009 Public Health Association of Australia

KEYWORDS

health • Timor-Leste • self-assessed • conflict • displacement • migration

ABSTRACT

Objective: Timor-Leste is one of the world's newest nations and became a democracy in 2002. Ranked 150 out of 177 in the 2007 UNDP Human Development Index, the country has the worst health indicators in the Asia-Pacific region. The objective of this study was to collect and analyse data on subjectively assessed general health, health service use, migration and mobility patterns.

Methods: The data collection involved recording self-reported status of general health using a structured questionnaire. The survey was administered to 1,213 Timorese households in six districts using a multi-stage random cluster sampling procedure. Basic descriptive statistical analyses were performed on all variables with SPSS version 13.

Results: More than a quarter (27%) of respondents reported a health problem at the time of the survey. Only approximately half of respondents assessed their health to be good (53%) or average (38%). Barriers reported in the uptake of healthcare services were no felt needed; difficulty in accessing services and unavailability of service.

Conclusions: Results reveal that Timor-Leste needs a more decentralised provision of healthcare through primary healthcare centres or integrated health services. Trained traditional healers, who are familiar with the difficult terrain and understand cultural contexts and barriers, can be used to improve uptake of public health services. An adult literacy and community health education program is needed to further improve the extremely poor health indicators in the country.

Implications: Key lessons that emerged were the importance of understanding cultural mechanisms in areas of protracted conflict and the need for integrated health services in communities.