Daniele Brombal, Curarsi è difficile. Curarsi è costoso. Storia, politica e istituzioni della sanità cinese, 1978-2013, Roma, Aracne, 2015, 167 pp. (ISBN 9788854883390).

Daniele Brombal’s book focuses on an extremely relevant issue – health care in the People’s Republic of China (PRC). In some respects, health care can be seen as a litmus test of the ability of the Chinese ruling class to manage the numerous imbalances, determined by the economic miracle that resulted from the reformist policy initiated by Deng Xiaoping in the late 1970s. Beyond the astonishing growth rates and a widely recognized absolute poverty reduction, the economic miracle has in fact given rise to serious imbalances and social inequalities, as shown by the fact that the Gini coefficient has risen from 0,16 (urban) and 0,21 (rural) at the beginning of the reform era (1978), to 0,46 (national average) at the beginning of the new millennium, well above the recognized warning level of 0,4. Not surprisingly, these increasing imbalances and inequalities have fuelled widespread social unrest over the years. For the Chinese rulers, health care reform remains one of the many challenges ahead, which needs to be urgently addressed, being compounded by the challenges represented by both a rapidly aging population and increasing levels of pollution. Three decades ago, only 5% of the population was over 65; today, 123 million people, or 9% of the population, are over this age; and a report released by a government think tank at the end of 2013 forecasts that China will become the world’s most aged society in 2030. With regards to pollution, it is one of the major causes of the increase in the number of diseases within the Chinese population.

In Curarsi è difficile. Curarsi è costoso. Storia, politica e istituzioni della sanità cinese, 1978-2013 [«To Take care of one’s health is difficult. To take care of one’s health is expensive»], Brombal provides a deep and meticulous analysis of the political, economic and social changes that occurred in China since the launching of the policy of reform and opening (gaige kaifang), in December 1978, during the Third Plenum of the 11th Central Committee Congress of the Communist Party of China. The gaige kaifang included the growing political and administrative decentralization, the de facto privatization of social services. This, in turn, brought about the establishment of strong economic interests, triggered pervasive social and economic imbalances within the population and, more recently, caused the regime’s attempt to promote social equity in order to ensure its legitimacy and stability to the regime.

This complex process is analysed in Brombal’s monograph by using the evolution of the health sector as a case study. In particular, the volume describes the serious social imbalances existing in China today; the dysfunction of the health care system, the preponderance of the private interests to the detriment of the health system consumers, the central government disengagement in relation to the health sector during the 1980s and the 1990s (strictly related to the belief of the substantial unproductiveness of all social sectors), the longstanding problem represented by the lack of enforcement of central government’s regulations by local authorities when these go against their interests and the general disinterest by the local authorities towards the citizens’ well-being.

In 2000, all the above factors brought the World Health Organization (WHO) to rank PRC’s health care system at the 144th place for its general performance (behind Burundi) and at the 188th place in terms of equity (in a general classification of 191 countries). This is in sharp contrast to the fact that, only 18 years before (at the end of the Maoist era and on the eve of the abolition of the Commune system), China had been considered an outstanding example of primary health care (p. 81).

During the 2000s, the lack of coordination and the laxity of a part of the administrative machinery in the field of health care became apparent, even outside the PRC’s boundaries, with the burst of both the Severe Acute Respiratory Syndrome (SARS) and Avian flu (or «bird flu») epidemics.

The author’s choice to concentrate the analysis on the rural areas is not accidental; on the contrary, it has provided awareness that the rural areas represent the «mouthpiece» of the contradictions that affect the Chinese system today. Going beyond «the limits of the coastal cities and the big industrial centres» allows the author to observe the «raw matter/first matter by which the so-called ‘Chinese miracle’ was fed» (p. 16).

In writing the book, Brombal has availed himself of a rich bibliography – including scientific articles, laws and government regulations, policy directives, propaganda and advertising campaigns – both in the Chinese and Western languages. But the strong point of the book is represented by the material collected by the author in the field, thanks to his sinological background and his language skills. Brombal has in fact carried out quite-difficult fieldwork research, especially considering that this kind of research is still viewed in China as a «sensitive activity» (p. 130). He has conducted interviews and accepted spontaneous witnesses among medical and administrative personnel, governmental officials, researchers, students of the Faculty of Medicine and employees of the pharmaceutical industry, in three Chinese provinces (Hubei, Shaanxi and Sichuan), in the autonomous region of Inner Mongolia and in the municipalities of Beijing and Shanghai. This impressive fieldwork has been part of a research project (headed by the author himself) funded by the Italian Ministry of Foreign Affairs (in particular the general direction of development cooperation) and realized in cooperation with the PRC Ministry of Health, between 2008 and 2011.

By making extensive use of the material collected in the field, Brombal’s monograph shows that, starting from the mid-1980s, different economic interest groups have acquired a remarkable capacity to influence the definition and the implementation of health policies in order to maximize their profits. This happened often with the connivance of the local authorities in charge of the health care management. In the last decade, these trends have had a profound effect on the ability of the central government to remedy the crisis in the health industry. This crisis was made more evident by the lack of access to health care by the most disadvantaged sections of the population, the widespread impoverishment due to illness and, finally, the outburst of the SARS crisis.

Brombal’s book is articulated in three chapters and a conclusion. The first chapter describes the evolution of the Chinese health care system from 1949 until today, focusing on the role played by the Party/State in supplying health care service in three different phases (1949-1983, 1983-2002 and 2002-2012), each one characterized by peculiarities that pertain to the different financial and distribution methods of health care services. The second and the third chapters are structured as case studies of rural health in China, aimed at demonstrating the working hypothesis, i.e., the fact that, beginning with the mid-1980s, different economic interest groups – formed largely by doctors, hospital managers and pharmaceutical companies – have acquired a considerable capacity to hack into depth on the definition and the implementation of health policies, in order to maximize their own profits. In particular, the second chapter analyses the modes that have allowed the proliferation of private interests in the health sector through the exploitation of the loopholes, the weaknesses in the existing regulations and the ability to promote the maximization of profits. The third chapter focuses on the impact of private interests on the health policies adopted by the administration, led by Hu Jintao and Wen Jiabao. In the conclusion, the author reflects on the failure of the health policy measures adopted by the Hu Jintao-Wen Jiabao’s administration in order to put an end to the distortions introduced by the neoliberal policies adopted during the 1980s and 1990s, both in terms of better access to health services and in terms of protection of the rural population from the risk of illness-related impoverishment. As a result, violent attacks against medical personnel by desperate people are the order of the day (pp. 156-157).

Brombal’s monograph closes with an interesting photographic appendix that witnesses the places and the people involved in the field research. A second appendix contains the results of the targeted and spontaneous interviews (112 in total) conducted by the author between 2008 and 2011 among medical and administrative personnel, governmental officials, researchers, Faculty of Medicine students and employees of the pharmaceutical industry. Finally, the volume includes numerous diagrams, graphics and tables that contribute to make it easier to read.

Curarsi è difficile. Curarsi è costoso. Storia, politica e istituzioni della sanità cinese, 1978-2013 represents a fundamental reading on contemporary China for both students and academics and for the general public, as well, offering the keys for a better understanding of the problems bedevilling the Chinese political leadership.