I recently returned from an illuminating visit to Hangzhou, China, a “small” city of 8 million people approximately 3 hours southwest of Shanghai. I was there to speak about human milk at an international meeting in celebration of the 30th anniversary of the first NICU in China. The meeting celebrated the support efforts of Project HOPE that inaugurated and accelerated the progress of neonatal care in China.1 The neonatal community there has grown tremendously over the past three decades and it was exciting to see a glimpse of their progress. They recently opened a new hospital, the Children’s Hospital Zhejiang University School of Medicine, a year ago and brought in up to date technologies, medical equipment and trained staff to manage an enormous number of infants each year, easily tripling or quadrupling the kind of volume we see here.
It was interesting to see how the Chinese are dealing with the ethics of neonatology and with the limits of viability. They have started to reach down to the mid 20’s gestation where we have been for a long time. Naturally this is associated with increased morbidity and mortality. However, since many patients do not have long term healthcare coverage, sick very preterm infants are often brought home to palliate as parents make the tough decision that the cost of care or the future morbidity is unmanageable or intolerable. The Chinese neonatal community is beginning to generate data on infant morbidity and mortality and such cases are classified as against medical advice or AMA. This represents a considerable number in each of the smaller gestation categories.
The Chinese medical community appears extremely avid to catch on to the latest neonatal advances from the Western world. By appearances, they have achieved breakneck progress in a short time. There are some areas, however, that are showing some weaknesses. The most significant one that is glaringly obvious is in nursing. Nurse to patient ratios are extremely high by North American standards, sometimes 8:1 or more and so contrast that to our 3:1 or 2:1 in a typical level 3 NICU in America. There are a more reasonable number of physicians including trainees and medical students that do a considerable amount of bedside work. Like in many places in the world, physicians are responsible for managing the equipment (including ventilators) and intravenous access. Nevertheless, I got a clear feeling that there were not enough caregivers to go around for so many small infants, and that everyone needed to work often and for long hours. Healthcare providers are a large cost but by no means the largest cost of healthcare and they are essential to providing the best neonatal care.
Parents were another interesting observation in China. In particular the one child rule has perhaps made parents particularly attentive to their one precious child. On the streets we saw open doting by all family members but most importantly by the fathers who were present in many family groups. This is in stark contrast to other countries where the father is often absent due to a longstanding culture of the primary breadwinner working long hours of work and attending after-work activities (post work drinking is very common in South Korea and Japan). I am aware of two units in China that are making the effort to participate in the family care model where parents are part of the care team, and so it will be interesting to see if this will have more traction in China than in North America since they typically only have one child and could spend more time at the hospital and nursing resources are so limited. This may end up being a highly practical solution for their nursing shortage. We have recently rediscovered that human interaction that includes tactile and verbal stimulation are an essential part of normal human brain development. The role that parents and staff play in this needs to be redefined in both our worlds.
Like many things, learning is a two way street. So what can we learn from China?
China, like several countries in Asia, is culturally based on Confucianism, and therefore has a basis for valuing the community over the individual and perhaps this is what makes it appear easier for the Chinese to gather as a team and work towards common goals. Nevertheless, the NICU is a special community we all belong to where we have an opportunity to push a communal agenda ahead of the individual needs to create a highly functioning team. There is opportunity to build a stronger cultural base that we can all support since we seek the common objective to make babies better that helps align us and improve our overall team performance.
Be open to new ideas
We all take time to change and this may be favorable on a preservational basis since hasty decisions may lead to unfortunate consequences, but in medicine we simply take too long to change to the obvious. In China, I got the feeling that they were highly eager to embrace new concepts and ideas. They were hungry to match our practices and make changes back home. What drives them could be a desire to offer the best for their people as well as a healthy competitiveness to be just as good as others in the world. Whatever their motivation, they were creating new opportunities for change rapidly compared to our system. Serving our patients to be the best in the world is not a bad motivation.
Seek the experts
Looking for the both the best experience and best evidence to change practice is the foundation of activities in quality improvement networks that have improved our capacity reach out to high performing units to assist low performing units mimic their practices. Medical evidence is now readily available, frequently updated and collated in comprehensive systematic review formats to help us appraise the most recent data. Medical conferences are increasing in China and the two that I have attended this year were held mostly in English with live translation. The fervor of learning is evident in each conversation I had with other neonatologists and participants as they were reaching out to learn an equally difficult language to Chinese so that they could improve the medical knowledge bridge between countries. There are experts around the world in different areas and we could learn from this type of outreach learning.
I came away from my two trips to China this year emboldened by the sheer power of human will. So much can get done with collective will and purpose. The hard working and efficient mindset of the Chinese people was truly admirable. Perhaps in some cases autocracy may drive change faster than anything else and leave idle discussion matters aside. Other times the efficiency could be drawn from the avoidance of questions towards authority as we see so prevalent here in the Western world. But most of all there was a relentless mission towards a goal that was unlike the experience my wife and I got almost being trodden by massive tour groups at the Imperial Palace streaming from one end to the other, each wanting to capture every moment in pictures with a purposeful flow to the end. Rapid and efficient change is happening in China.
The question still to ask though is if change can happen faster here in the US. We need to ask ourselves what we want the world of neonatology to look like for the future. What is our role in this future? What technologies would be great to make this happen? How do we want to be caring daily for our babies? How will we deal with ever lowering limit of viability? I am moved seeing how connected we are now to the rest of the world and that we perform on a world stage to show what the best resources, technologies and science can produce. The impact of what we do here has an influence on a massive number of babies born in this world. Information flows more freely than ever across the world and we have a unique opportunity to share the knowledge that we have learned to help others attain the same success. We also have much to learn from other cultures and neonatal practices. It’s time to dream big and set lofty goals, don’t you think?
1. Peabody JW, Hesketh T, Kattwinkel J. Creation of a neonatology facility in a developing country: experience from a 5-year project in China. Am J Perinatol. 1992 Sep-Nov;9(5-6):401-8. PubMed PMID: 1418144.