China nearly killed me

Flying back to Beijing after a period of absence, I feel the familiar anxiety. As I leave the airport and breathe the morning air, I glimpse the sun, a smudgy disk floating in a haze of carcinogenic particles. Just over two years ago, after living and studying in the city for more than three years, I was diagnosed with cancer of the throat. One evening in my apartment, poring over a story by the Chinese author Lu Xun (which, as it happened, was called “Medicine”), I discovered a large, painless lump on the side of my neck. I called a friend in London who had had cancer—Hodgkin’s lymphoma—and described my symptoms. He said it was probably nothing to worry about. I was reassured. As I was busy at the time, preparing for my exams at the Beijing Language and Culture University’s “Intensive College,” I decided to postpone a visit to the doctor. After a long period of reasonably diligent study, this was my only chance of graduating from their highest level, a trivial achievement, no doubt, but the “biye zhengshu” (graduation certificate) would at least be something tangible to show for my time in Beijing.

Three weeks later, on the day my exams concluded, I took a taxi to the the International Medical Centre. An Egyptian doctor examined my throat, looked at me gravely and said: “We cannot rule out bad things.” He sent me to the “Tongren Yiyuan”, the Mutual Benevolence Hospital, one of Beijing’s best, established by an American missionary society in the late 19th century. As I entered the hospital, the atmosphere was one of palpable desperation. Every day patients and their families flood into the reception area and register for an appointment. Many have queued all night to get an early appointment the next day. Some have succumbed to ticket touts who scoop up dozens or hundreds of registration tickets and sell them at an exorbitant profit.

For the patients, however, obtaining an appointment is just the beginning of their troubles. There is a queue and a fee for every service the hospital offers. Many have come from the remote countryside in the belief that only a city hospital will do. They can wait for days, or even weeks. And while they wait, they stay in cheap, grim hostels or sleep on floors. You see these families, often with an aged relative on a gurney, desperately shuttling from one kiosk to another, paying at each location for scans, medicines and services, until they run out of money.

In China, trust in doctors is low. Health services are profit-driven. They ration provision according to the ability to pay and, although a few years ago the government introduced state health insurance payments, they are set at a low rate and demand co-pays, which many cannot afford. Unless you are rich, you can expect long waits and cursory attention from harassed staff. The system is based on the American model, but is even more ruthless. In a country where the great majority of people are still extremely poor, the only sound advice is not to fall ill. That is exactly what the Chinese say: “Whatever you have, don’t have an illness...”  (“You shenme, bie you bing”), and the less easily translatable but even more sardonic, “Mei shenme, bie mei qian,” “Whatever you don’t have, don’t fail to have money.” For many millions of Chinese over the past 30 years, especially in the countryside, falling ill has been a death sentence. And for many, it still is.

A Chinese friend recently told me about her uncle, a man in his seventies. One day, he was crossing the road when he was hit by a car. Despite being badly injured, he managed to make his way home. He needed medical treatment but did not have the money for it. He reflected that he had had a long life, and did not want to be a burden on his family. A few days later, he went to the nearest reservoir, threw himself in and drowned. This happened four years ago in Beijing. In my experience, Chinese people, hearing a story like this, will nod their heads in recognition.

Earlier this year, after a spell of clear, cold weather, the sun disappeared and a thick grey mist descended. Looking through the window of my seventh floor apartment, all but the very closest blocks were lost to view. This had happened frequently during the four winters I spent in Beijing, but rarely so dramatically and never so persistently. Each morning, as the days passed, I looked out of the window to see the same pale, grey light, the same sunless sky and the nearby buildings fading into the toxic mist. A fortnight passed, and the city was still suffocated by “wumai,” “fog-haze” or “smog.” Even indoors, my eyes were smarting and there was an ashen, gritty taste in my mouth. When I went out, I took to wearing a mask, like many of the city’s inhabitants. It was hard to tell whether the mask was doing me any good but, feeling I was making a stand, I kept it on. A Chinese friend, an economist in her early thirties who, during her twenties, had studied for eight years in Sweden and the United States, told me that, until now, she had always thought complaints about Beijing’s air quality were just foreigners’ whining.

My own story offers persuasive evidence of the scale of the problem. It began, in the autumn of 2011, with a tickling sensation in my throat. I first noticed it after eating an orange during a break from class. I ignored it for a couple of months—it wasn’t painful, just mildly irritating, and I was absorbed in my studies. I did feel rather more tired than usual, but put that down to my schedule. I was also losing weight—about 15 pounds in three months—but I attributed that to stress. It was only when, in December, I noticed the lump on my neck that I realised something was not right. I still did not connect the two symptoms—the tickling in my throat and the swelling on my neck. As it turned out, both were signs of a cancer which had begun in my throat and spread to the lymph nodes in my neck.

The aetiology of cancer is generally hard to establish, and causation is often determined on a statistical rather than clinical basis. My particular cancer is thought to have three possible causes: probably the strongest link is to smoking; others cited are excessive alcohol consumption and the HPV virus, which can be acquired through oral sex. I don’t smoke, rarely drink and wasn’t carrying the HPV virus. However, there’s reason to suspect that Beijing’s atmospheric pollution played a role. In China, cancer is now the most prevalent cause of death. Lung cancer is the most common form of the disease, its incidence having risen by 465 per cent over the past 30 years. Other forms of cancer connected with the respiratory organs have also proliferated.

If you look at the figures, it is not hard to understand why this should be. International air quality assessments are based on concentrations of PM2.5 (“PM” stands for “particulate matter”). The World Health Organisation (WHO) designates particulates a “Group 1 carcinogen”: they are thought to be the most dangerous form of air pollution, due to their ability to penetrate deep into the lungs and bloodstream. PM2.5 “fine particles,” with a diameter of 2.5 micrometres or less, are the deadliest of all—the smaller the particles, the deeper they penetrate. A Danish study published last year, involving over 300,000 people in nine European countries, showed there is no safe level of PM2.5: for every increase of a millionth of a gram per cubic metre of air, there was a 36 per cent increase in the incidence of lung cancer.

PM2.5 concentrations are measured on a scale running from zero into the hundreds. According to the WHO guidelines, any PM2.5 reading of over 10 micrograms per cubic metre is hazardous to health. In Europe and the USA, readings of under 20 are considered “good” or “moderate”; readings of over 35 are thought “unhealthy” or “high”. The US classifies over 250 as “hazardous”; Europe thinks of it as off the scale. The Chinese government’s view of these matters is rather different. By its measurements, any reading under 150 is “excellent,” “good,” “light” or “moderate”; over 150 is “heavy.” In other words, the Chinese consider atmospheric pollution serious only when it reaches 15 times the WHO-designated safe level. According to the WHO, the 10 US cities with the highest PM2.5 readings range from Washington, with a reading of 10.6 to Bakersfield, California, with a reading of 18.2. Meanwhile, the top 10 Chinese cities range from Zhengzhou, at 102.4, to Xingtai at 155.2. These are merely averages, and they significantly understate the problem in China. Over the past year I have spent several months in Beijing. In February, when smog enveloped the city for weeks, readings from instruments on the roof of the US embassy were consistently showing PM2.5 readings of above 500 and for some of the time touching 700.

The authorities announced in February that official data on pollution, formerly secret, should be made public. The Economist, the kind of serious western publication that treats every utterance of the Chinese authorities with pedantic respect, hailed this as “an important step” that signalled “the beginning of a move towards openness.” The magazine also noted the widespread evasion of such targets and regulations in China. There are national targets for the control of carbon dioxide emissions per unit of Gross Domestic Product, for a limit to the quantity of coal that may be burned and for compulsory installation of pollution-control devices on factories. All are routinely ignored. The Economist explained that such controls operate through the central-planning system, which gives insiders—managers of enterprises and local officials—every chance of getting away with pretty much whatever they want to.

The Chinese system is an insiders’ system, of course. Even if the government is serious about the targets it sets, it is easy for these to wither quietly in a desert of bureaucratic obstruction, corruption, indifference and sheer incompetence. A Chinese acquaintance once told me that a government slogan should almost invariably be understood to mean its opposite: if the stated aim of the government is “a harmonious society” (“Hexie Shehui”)—the portentous phrase, echoing Confucian precepts, that was propagated as the kernel of former President Hu Jintao’s political philosophy—then the reality of Chinese society must be the opposite, a society riven by competition and conflict. In the same way, a government announcement does not mean that something will be done to solve a given problem. It merely means that the government recognises that there is a problem and that people are anxious about it. And quite often, the announcement is the action.

At the height of last winter’s smog—which was not just the worst I had experienced in my time in the city, but also the worst my wife, a Beijinger, had known in 40 years—the authorities announced measures to reduce atmospheric pollution. One was a ban on roadside barbeques. “Lu bian shaokao” are run by migrant workers, and offer roast meat on skewers. They are popular here, but also controversial. Apartment dwellers regularly complain to the “chengguan,” the neighbourhood police, about the smoke and aromas invading their flats and about food poisoning from insanitary cooked meats which they or their children have eaten.

The food stalls have a place on the long list of complaints which Beijingers bring against the “waidi ren,” the “outsiders.” According to many “lao Beijing” (literally, “old Beijing,” those born in the city to Beijing families), the outsiders are dirty, uncouth, often criminal, indifferent to Beijing traditions and, with their impenetrable dialects and regional accents, incapable of speaking “putong hua” (“common speech” or standard Mandarin). These prejudices are widely and stridently held, if extremely unfair. Meanwhile, everyone knows that government measures against roadside barbeques are, so to speak, a smokescreen. In the same vein, the authorities announced measures to limit “Chunjie”—Spring Festival—fireworks. For a fortnight each year, all over the country, the sound of firecrackers can be heard day and night. This is a virtually unassailable tradition, but each year there are hundreds of accidents, particularly involving children. For the government, controlling the sale of fireworks, like suppressing roadside barbeques, is a low-cost route to popularity, clamping down on an activity many dislike while appearing to be taking measures to improve urban air quality.

Yet few believe that historic levels of atmospheric pollution in Chinese cities are caused by fireworks and barbeques alone. Beijing is far from being the most polluted city in China, but because it is the capital and large numbers of foreigners live there, it receives particular attention. It is ringed by Hebei province—on some measures, the most polluted of China’s 32 provinces—where thousands of factories spew coal smoke into the atmosphere. And like other northern Chinese cities, Beijing’s “gong nuan,” its central heating systems, are communal. From the middle of October onwards, heating in most apartment blocks in the city is provided by a coal-fired central plant which pumps hot water, day and night, to the block’s radiators and smoke into the atmosphere. Finally, there is Beijing’s traffic: over five million cars are registered to city owners. These clog the roads daily, emitting all the usual pollutants, along with some that are less common in more developed countries which have a larger stock of newer, more energy-efficient vehicles.

Nonetheless, the authorities continue to insist that the shao kao stalls and Chunjie fireworks are the problem. As one Chinese friend of mine put it: “The government looks for the weakest groups and then bullies them.”

In February, President Xi Jinping went for a walkabout in Nan Luo Gu Xiang, one of the earliest of Beijing’s “hutongs,” its medieval lanes, to be gentrified. Now equipped with boutique shops and cafes, it has become an attraction for visitors and leisured Beijingers alike. Xi and his handlers are practised in modern media management and are fond of stunts. His widely publicised “Chinese Dream” slogan, first promulgated in late 2012, was an early example. Xi’s purpose in hanging out with the people during an unprecedentedly bad period of wumai was to reassure them that the Party is with them. He was followed by a posse of department heads and ministers, all enacting, under his command, a well-known saying from the early Maoist days: “Tong huxi, gong mingyun.” It means: “Breathe the same air, share a common destiny.”

Many Chinese believe that atmospheric pollution is one problem the leaders cannot ignore: “They can eat their own food,” a friend said. “They can go to their own hospitals, live in their own compounds, educate their children abroad, but they can’t breathe their own air.” It’s a persuasive argument, but Xi’s remarks in Nan Luo Gu Xiang suggested that he doesn’t feel the issue is particularly urgent. “In the face of problems,” he said, surrounded by a battery of television cameras, “we shouldn’t be too anxious; we should apply the calmness we’ve gained from our life experience.”

Xi looked back on his Beijing childhood: “I wore a mask when I cycled to school. By the time I arrived, my mask was thickly covered with yellow sand. When winter came, there was also the coal smoke, and the situation was even worse. At that time there was no PM2.5, but there was PM250.” This last remark was the key to the whole scene. It was a play on Beijing slang in which to describe someone as “250”—“erbaiwu”—is to say that they’re a fool. (In Chinese culture, numbers have a mystical significance, partly because of their homophonic qualities. For example, “si,” “four,” is homophonic with “si,” “death”.) Xi’s witticism provoked the expected laughter. He concluded: “We have solved our former problems, and now we face new ones; in fact, in Chinese society, old and new problems exist side by side.”

Xi’s words were meant to reassure people that the Party had the problem under control. Yet, most years, spring sandstorms from Mongolia still blow into Beijing, just as they did 40 years ago, while the atmospheric pollution has grown dramatically over several decades. According to a former government official of my acquaintance, the President hoped to combat the “widespread sense of depression about the Chinese model of development.” The country’s environmental problems are a reflection of its explosive economic growth, but also a metaphor for anxieties which, despite justifiable pride in the country’s recent achievements, grip large numbers of Chinese people. Many of those anxieties are financial: average incomes have risen strongly in recent decades, but the income distribution is drastically unequal. Western celebrations of Chinese growth rates largely ignore the hundreds of millions who teeter on the edge of financial disaster, or have already fallen off the cliff, let alone those who haven’t even reached the lowest ledges of security.

The casualties of government policies are concealed by growth statistics. Another recent article in the Economist, describing three decades of migration from the Chinese countryside to the cities, announced: “This extraordinary revolution has been surprisingly smooth—there are, for instance, very few shanty towns of the sort you see in Brazil or India.” The writer evidently hadn’t spent much time wandering around the cities he or she was describing.

In 2009, I was living in northwest Beijing in a “xiao qu,” a “little district,” the name for a group of high-rise apartment blocks with their own shops, services and playgrounds. Crossing the road behind the blocks, I found myself in a shanty town where “waidi ren,” migrant workers, lived in small shacks. Children ran on rough, unpaved tracks and women washed clothes in bowls of water filled from a stand-pipe. They looked at me with the suspicious eyes that any outsider, and particularly a foreigner, would naturally attract. Their faces were ruddy, raw from thousands of days spent out in the open.

These were some of the “bei piao,” “floating in Beijing,” the name Beijingers give to the millions clinging on in the capital in the hope of making a living or changing their destiny. Figures are hard to come by, but “waidi ren” in the major cities are generally estimated to be 35-40 per cent of the urban population. Some have money and decent jobs, but many millions do not.

I wandered for quite a long time that day. The shacks ran down to a brackish lake. Looking along the bank to left and right, I could not see the end of them. A few months passed—I was busy with my studies and didn’t go back until the summer. When I did, I found that the town had been bulldozed. All that remained were a few shacks surrounded by rubble. There were still a handful of people clinging on, but they too were destined for removal.

This is how it is. One day the character  (“chai”) will appear roughly whitewashed in broad strokes on a wall, and the next day the place where you’re living will vanish. “Chai” means “to dismantle or to demolish.” In another pronunciation—“ca”—it means “to shit, to piss,” literally “to discharge.” A little while later, in place of the squatters’ village, a luxury hotel and expensive apartment blocks started to go up. It is the same story all over the country: local authorities do deals with developers, palms are greased, a few people get rich and the people on the land lose all they have.

An encounter with cancer leaves scars, but, if you are lucky, you will recover. I was lucky. My cancer was relatively treatable, and I caught it fairly early on. The specialist at the Tongren Hospital in Beijing looked at my scans for two or three minutes and said that, if I was to survive, I required a 12-hour operation as soon as possible. There was no discussion, and no alternatives were offered. I decided to return to London for treatment.

A French friend, who had spent three years researching the Chinese health system near Wuhan, commented in an email: “I recognise very well the Chinese medical environment from your description: dramatisation of the situation to the highest level to ensure that patients’ mental health plummets to the level of their diagnosed physical health, leading to acceptance of the most intrusive (and lucrative) intervention; forecast of a small likelihood of a successful outcome for this intervention so that the doctor in charge can be revered as your saviour upon recovery (and possibly earn a fat “hongbao”). You escaped at the… right time.” The “hongbao” is the famous red envelope containing cash, which remains an unavoidable part of the search for decent medical treatment in China.

As I say, I was lucky. I was able to fly back to the UK, where I received the best possible treatment. After 35 sessions of radiation, and a few episodes of chemotherapy, I was sent out into the world to recover. It took about a year, but the prognosis is good. I still visit Beijing, but I’m not living there. I can leave when I like. Millions of Chinese are not so lucky.