The frigid morning was still blanketed in darkness, but Nie Xiaojuan was awake and holding tightly her place in line. She had just spent her fifth straight night sleeping on the floor of Beijing Union College Hospital’s registration hall, which was minutes away from its 6:30 a.m. opening.
Appointments for the best doctors are normally snapped up before sunrise. Lines begin forming in front of the hospital’s six registration counters at least a day in advance. Nie’s father, who was too weak to join the queue, needed to see several specialists. Nie had no choice but to stake out a place night after night so that each morning she could arrange a single appointment.
Around her hundreds of patients and family members filled the hall, a dimly lighted space about the size of a tennis court. Each evening it turns into a campsite. A woman from a coal town seeking an appointment with a liver specialist dozed on a pile of jackets. A janitor sat on a copy of the Beijing News, holding a place for his cousin with kidney problems. Many in line passed the time by playing cards, knitting or dozing. When people needed to use the toilet or run to buy food across the street, neighbors in line held their place.
Nie, who traveled 250 miles from Inner Mongolia by train, was lucky to be first in her line, boosting her odds of getting an appointment with one of the hospital’s coveted medical experts. But even that was no guarantee. Patients with pull -- and plenty of cash -- don’t bother with queues. Scalpers who line up as if they were patients or collude with shady registration clerks snatch up many of the slots and sell them to the highest bidder.
“The whole week we’ve been lining up,” said Nie, 20. “What else can we do?”
At a time when the United States is grappling to overhaul its healthcare system to provide more Americans with coverage, China is struggling with the fallout of abandoning its socialist model in favor of Western-style privatized medicine. Government efforts to modernize China’s healthcare system and reduce Beijing’s role have led to deep funding cuts for public hospitals. Rural clinics have been hit especially hard.
The results are familiar to many Americans: Patients with good health insurance or ample savings can get first-class treatment at the best medical facilities, while millions of the uninsured and poor live in dread of a serious illness that could bankrupt their families. Hospitals are focusing ruthlessly on the bottom line to stay afloat. Costs are soaring, in part because of perverse incentives that encourage doctors to prescribe pricey drugs and needless tests.
Concerned that its rickety healthcare system could destabilize social harmony, China’s central government has launched a $124-billion overhaul, chiefly to improve service in rural areas. Failure to address the nation’s health woes could be disastrous not only for China -- home to about a quarter of the globe’s population -- but also for the rest of world because of the threat of rising communicable diseases such as H1N1 flu.
“The issue in China is ultimately about access to healthcare,” said Jonathan Samet, director of the Institute for Global Health at USC. “China, as a rising power, has to figure out how to care for its citizens.”
Nie (pronounced NEE-yeh) and her family live on the rural fringes of the provincial capital Hohhot, a popular tourist destination tucked between two mountain ranges in north-central China. Until last spring, life was ordinary for the most part. Nie’s father was a truck driver and her mother a chef at a neighborhood restaurant.The family could live on its $350 monthly income.
Then in April Nie’s father was seized with back pain. He could no longer drive. He started feeling lethargic and lost weight at an alarming rate. Nie took a job as a waitress at a restaurant to help make ends meet.
Six months later, doctors at a village clinic and county hospital were still stumped for a diagnosis. The family decided its only hope was to seek out experts in Beijing. Nie’s father knew of Beijing Union and was convinced he would be cured there.
“It’s the best, and ordinary working class can be treated there,” said Nie’s father, Nie Gencheng, 44.
The family pooled its savings -- a few thousand dollars -- and father and daughter headed for Beijing. Their local insurance would not cover them there, and the money would be needed to pay the specialists.
For decades, Beijing Union, in the heart of the capital, has been considered the gold standard in China. The storied institution was founded in 1921 by the Rockefeller Foundation and is attached to a prestigious medical school whose colorful tiled roof evokes China’s imperial past.
But as the healthcare system has broken down in rural areas, peasants have flocked to the cities, overwhelming medical centers such as Beijing Union, where about half of the 8,000 patients seen there daily hail from other provinces.
“Everyone is chasing a higher level of care,” said Zhou Shengli, vice president of Beijing Anzhen Hospital, another top facility plagued by long lines and scalpers. “These few [dozen] hospitals can’t treat 1.3 billion people.”
The surge in demand feeds a black market for medical care. Packs of scalpers roam China’s major hospitals, peddling appointment tickets for hundreds of dollars -- equivalent to months of earnings for a typical peasant. Despite periodic crackdowns by authorities, these hustlers operate freely outside Beijing Union’s registration hall, a squat one-story structure flanking the main hospital building.
“Dr. Tang. Dr. Tang. Who wants a ticket for Dr. Tang? Rheumatology and immunology,” a man repeated to passersby one recent evening in plain sight of guards. Other scalpers passed out handwritten business cards promising appointments with any physician.
Nie quit her restaurant job to accompany her father. It was her first visit to the capital. She and her father rented two beds at a hostel for $10 a night and strategized about how to register.
Calling proved futile; the hospital grants only 200 telephone appointments a day. An experiment with online registration ended years ago after patients booked half a year’s appointments in a matter of hours.
It was first-come, first-serve, so Nie had to join the queue. Her father, wearing the same shabby pinstripe pants and blazer each day, could only muster the strength to stay with her in the afternoon. Nie was on her own at night. She bought foam tiles to sleep on.
The first day, she stayed at the hostel until the afternoon, then left for the hall, prepared to spend the night. She signed in with a guard for the department her father was seeking and grabbed a spot in the shortest line. She woke up in the morning, waited for her turn at the counter and took a white ticket printed out by the clerk’s computer that granted her father an appointment with a bone doctor that same day. The next morning she secured an appointment with a pain specialist, then the next morning a heart physician. None knew what to do to help her father.
“Every time we got the same answer,” Nie said. “ ‘It’s nothing serious, just be careful with your dad.’ ”
Nie and her father grew frustrated. The problem, they believed, was that they needed to see the hospital’s chief neurologist -- one of the hardest appointments to secure. They figured their only hope was for Nie to get to the front of one of the lines.
After the third night in the hall, Nie decided to camp out there during the day instead of going back to the hostel. She put her name down for the neurology department and planted herself and her belongings in front of one of the counters.
But when morning rolled around, the clerk told her the chief neurologist wouldn’t be in that day. She would have to wait until tomorrow if she wanted to get her father an appointment with him. Nie didn’t want another doctor. Once again, she signed in with the guard and staked out a place at the front of one of the lines.
The night passed quietly, interrupted only by a few snores. At 6 a.m., the crowd was jarred awake by a security guard ordering the lines to be straightened and rented folding chairs to be returned. A loud public address system pierced the stillness, and digital billboards flashed on, displaying schedules for physicians and departments.
Tension mounted as an even larger crowd gathered outside. A security guard shouted at a woman he suspected of being a scalper, throwing her identification card on the ground.
“You villager!” the woman shouted back, a jab meant to insult the guard’s social status.
At 6:30 a.m. the registration clerks removed their “No Service” signs and called people forward.
Nie, her eyes puffy from lack of sleep, collected her things and approached the counter. She requested the neurologist and was given a white ticket by the clerk. She looked at the doctor’s name on the appointment slip and sighed.
“This one was our third choice,” she said, too exhausted to reject the appointment.
By getting to the front of the line, she thought she had finally worked the system to her advantage. But a scalper might have bought the tickets for the doctors that Nie and her father preferred long ago. Or those at the front of other lines may have been seconds quicker. Still, she felt like she only had herself to blame.
“Maybe I just wasn’t fast enough,” Nie said.
Nicole Liu in The Times’ Beijing bureau contributed to this report.