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The Future of the U.S. and China Health Care and Win-Win Opportunities

Lincoln Chen talks about how China Medical Board helped to build PUMC and bring world-class medical knowledge to China in the last century. He underscores that through mutual cooperation and two-way exchanges there are Win-Win opportunities for both the U.S. and China in competition and corporation.

“There is an opportunity for cooperation in China. That is a Win-Win both for China and the United States, but especially for the global health community, for all around the world.”

Lincoln Chen, President, China Medical Board

Following are the speech transcription:

The cooperation or competition between the U.S. and China -- is one of the greatest global dramas of our contemporary time. Indeed, I will argue that this growing tension is also an opportunity that will be playing out over the next several decades. How the world and we navigate this relationship will be very important for not only the health of the people in the United States and China but indeed it could contribute to peace and development in the world. So that's why the title of my talk is U.S.-China Health: Opportunities for Win-Win cooperation. History can teach us a lot about the Win-Win (and maybe the lose-lose) aspect of that U.S.-China relations. So my presentation is going to start with a very brief history of my foundation, the China Medical Board, and how we worked for the first 100 years on one way U.S. to China medical knowledge transfer, and how we're moving to two-way equal mutual exchange. These shared exchanges present opportunities not only for the U.S. and China but for the world.

China Medical Board was started in 1914 by the Rockefeller family through the Rockefeller Foundation. It was the Foundation’s second program as the Foundation started in 1913. At that time at the beginning of the 20th century, there was great scientific excitement about the discovery of the germ theory and the potential for eradicating the disease through knowledge to reduce human suffering and pain. Indeed, many believe, at that time, that the germ theory would also lead to solving social problems like illiteracy and poverty. Of course, that was a little bit too ambitious. But Rockefeller decided to try to create a modern medical school and hospital in China. The CMB (China Medical Board) was created as an instrument to do that work. The goal was to bring modern medicine into China by creating the Peking Union Medical College and Hospital. At that time, Westerner's called China the “sick man of Asia.” Life expectancy was only in the 30’s. Many people were dying prematurely, especially children. Therefore, the China Medical Board built the Peking Union Medical College (PUMC) and Hospital.

The campus that's still there next to Tiananmen Square. These are Qing's style buildings, that are the headquarters of the Medical School, and also the Hospital. I might add that PUMC is among the leading medical institutions in China today, a century later. China Medical Board built these buildings. By the way, the architect came from Boston and worked in China. And this land belonged to Prince Yu of the Qing Dynasty. That's a very sad history because he died, and his widow needed money. She sold her palace to the Rockefellers, who then built this complex, which is quite large immediately next to Tiananmen Square. It's a lovely campus and my offices are on this beautiful campus.

100 years ago, when we started, there was a revolution going on in modern medicine. The Flexner Report of 1910 transformed the scientific basis of American medical education as demonstrated by the transformation of teaching and the curriculum in Harvard Medical School. The Rockefeller Foundation funded the modernization of Johns Hopkins and Harvard Medical School. Most of the training of Harvard Medical School was through apprenticeship. Rockefeller endowed the Harvard Medical School to have a full-time medical faculty, both at the undergraduate, but also in the hospitals at the post-graduate level. The same thing happened with the modernization of nursing and public health, through respectively the Goldmark and Welch-Rose Reports.

Over the 20th century, China Medical Board helped China by bringing world-class academic excellence to China, and the PUMC programs were modeled after Johns Hopkins and Harvard. Indeed, not many know that Harvard President Eliot helped to found PUMC because he was a board member of the Rockefeller Foundation in 1913. Actually, we have records of his letters about listening to the Chinese in building and running the PUMC. One of the early deans at Harvard Medical School, Francis Peabody, was among the founders of PUMC. The Chinese Academy Medical Sciences was developed in the 1950s based on the Nanjing Health Medical Research Institute, which was under the Kuomintang (KMT) government but shifted to Beijing, and then eventually merged with PUMC. The China Medical Board attemped to bring the best world-class faculty for developing the curriculum at PUMC, including the very famous physiologist, Walter Bradford Cannon, who was a professor here at Harvard Medical School. Interestingly, his daughter Wilma was living with him in Beijing when she wanted to marry John Fairbanks, and John Fairbanks went to China and married Wilma Cannon in Beijing. And of course, he is the founder of China Studies at Harvard now called the Fairbank Center. So, there's a long, rich history of transfer excellence, especially between Harvard, China Medical Board, and the PUMC. Initially, all of the faculty at PUMC were elite medical leaders like Walter Bradford Cannon. By the way, Walter Bradford Cannon's grandson, Walter Bradford Cannon III, was a medical student at Harvard Medical School. He was one of my roommates when I was at the school.

In any case, the goal was that ultimately PUMC would be entirely Chinese owned, Chinese operated, and Chinese funded to be a world-class, excellent medical school and hospital, not a second-class development. And that's really where PUMC and PUMCH hospital are now headed. So that was the first century, the 20th century of CMB’s work and PUMCH in China. But what has happened in the hundred years of applying that strategy in the US and China?

There was a huge gap at the beginning of the century and now convergence in the life expectancy achievement between the two societies. China has rapidly accelerated its health improvement, but these data are around 2000. So, there I have data that China has gotten even closer to U.S. life expectancy as the U.S. has dropped a year or two most recently. You had in 1918 the influenza epidemic in the United States, also in China. But, then the war and the famine in China had huge effects on life expectancy. Now, that has been mostly corrected through the acceleration of better living conditions and more access to modern and traditional health care. The current situation, show some bumps in the road. The trade tensions are significant, and we don't know whether or how they'll be resolved. I'm predicting that the tension between competition and cooperation will persist for several decades. And what eventually is done by many of us, China Medical Board, but also all of you will determine the balance in that relationship.

We have now increasing tensions between the US and China. That's not new. Everyone is aware of that. In China, our China Medical Board is registered as a nongovernmental foreign organization under the purview of public security. We have actually welcomed this oversight and we cooperate fully, but the bureaucratic procedures are onerous and expensive. That's what I worry about because everything is done in Chinese according to public security's administrative procedures. But we comply and we work freely and happily with our Chinese colleagues. So, in substance, we've had no difficulty whatsoever except for time and money for administrative compliance. But we've had no interference in any way. We've continued to enjoy a very fine relationship with our colleagues. Indeed, as I mention, those lovely Qing style buildings we speak, PUMC hospital gave us back to sections of the ground floor of the courtyard building and we completely modernized the Qing dynasty atmosphere by doing what Rockefeller did originally in building the building, which is to create a modern office but enhancing the Chinese art and architecture. Now we are a showcase for the hospital where all the hospital units walk through our building, our new office. And they are now continuing to renovate the entire hospital. They're using the same architect who, by the way, is a graduate of Harvard. He worked with IM Pei in Suzhou. In America, based on my personal and professional experiences, I can say that there is more oversight by the U.S. government, not only in health but across all the departments. I was a speaker at the National Academy of Medicine Presidents’ Circle in April this year, and many U.S. government departments spoke at that bilateral senior-most technical-scientific conference. And what I heard alarmed me because the U.S. government, in all the departments, spoke of more aggressive oversight of U.S.-China activities. Frankly, as a Chinese American, many of my colleagues feel more and more uncomfortable with the reporting and the attitude, not only in the government.

I was born in China and I came here in 1947. But it was only in 1943 that the Chinese Exclusion Act was eliminated. And that had been started in the 1920s where there were fears of the “yellow peril” and Chinese were forbidden from immigrating to the U.S. Indeed, my father obtained his Ph.D. at Harvard here between 1936 and graduating in 1941. Despite World War II, he went back to China because he wanted to serve China. But also, he could not stay and work in the U.S. because of the China Exclusion Act. It was only because of the nationalist-communist war that my family fled to come to the US. Similarly, we at CMB also left China in 1951 because the government expelled us. But that same Chinese government sent a delegation to New York in 1981 to invite us to come back. So, CMB board tried to decide whether to go back and leave the rest of Asia to which it had shifted. Like Solomon, my Board said, we'll go back, but we're going to stay in other countries in Asia as well. We're now in both China, also we work in other parts of Asia.

There are right now opportunities for Win-Win mutual progress for several reasons. Disease burdens are similar between China and USA and thus treatments and solutions can be shared. Also, as health becomes more globalized, China and US can join together to improve health for all. The disease profile in China and the U.S. now are very similar, and both are struggling with very complicated health care systems that are extremely difficult to navigate and manage, because of the combination of the public sector, private sector, with social and commercial forces driving these two health care systems.

There are many lessons in the U.S. that the Chinese are keen to learn. We are, for example, trying to help the Chinese at their requests to improve the whole accreditation and certification of physicians, nurses and other health professionals. This requires considerable professional oversight, not just government activities. And the Chinese government is more used to government-handling these things that how China will combine government action with professional engagement is really uncertain. Our CMB trustee, Jordan Cohen, who was president of the AAMC (Association of American Medical Colleges) in the United States, has argued that it took the United States 100 years to develop the ACGME (Accreditation Council for Graduate Medical Education). There was a negotiation between the AMA (American Medical Association) and the professional groups, and other stakeholders, which has reached its current state. I have no idea how that will evolve in China. But there are many Chinese lessons that the Americans can take, I think the whole Chinese success at immunization. China doesn't have a measles outbreak like we have in the U.S. China’s insurance consolidation is very impressive. And of course, traditional Chinese medicine has much to offer. I'll just simply show this graph of insurance coverage between the U.S. and China because China is moving quickly toward a single-payer system. And it has the power then to grow that insurance system for three systems to be consolidated into one national system, whereas in the U.S. lack high coverage. But we're struggling with how to manage the integration of insurance with the public and the private systems.

There is an opportunity for cooperation in China. That is a Win-Win both for China and the United States, but especially for the global health community, for others around the world. The U.S. has been a pre-eminent leader in global health, but China, as you can see, has grown very quickly in its economic and political might around the world. And it has become very energetic in global health with a foreign aid agency. The Belt and Road Initiative actively participated in WHO and governance, and then finally in joint partnerships working with American systems. These last slides shows the very rapid increase of China's foreign aid. The next shows the coverage of the Belt and Road Initiative, which you all know, mostly involves infrastructure, less health, but it's inevitable that health will be part of that. By the way, you should know that obviously when you put in trains, planes, and roads that people will move, but also diseases and knowledge will transfer across the Belt and Road Initiative. This is China's active participation in global health, governance, and activities, and it's becoming more and more a major contributor. One example of U.S.-China cooperation is their joint work on Ebola control in West Africa where Chinese and the U.S. sent epidemiologists for disease control. The Chinese sent the largest-ever overseas deployment of medical personnel coming mostly from China CDC, but also from its own military to help contain the epidemic. And it's really in that epidemic that the Chinese and the Americans realize that Africa needs also an African CDC. So, this is a new partnership with the African Union. Both the Americans and the Chinese are helping Africa build an African CDC, and they're playing complementary roles. The Americans are sending their epidemiology intelligence service as a model for development in Africa. China is donating a building for the African CDC and it has sent a few staff to observe the American FETP (field epidemiology training program). This partnership is working very nicely to help Africa.

I do think we are entering a new era of the 21st century where China and the U.S. will be both competing but also cooperating. And this U.S.-China Summit, for which I have to compliment Yuanli Liu and Jing Ma for having founded and now grown, is a very important part of the more harmonious and mutually beneficial component of the U.S.-China relationship into the future. Much good can come from this Summit, both for U.S.-China relations and for health in these two countries, but also for global peace, development, and health improvements around the world.

Thank you very much.

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