Wall Street Journal - July 10, 2007
Nicholas Zamiska, nicholas.zamiska@wsj.com

"I was scared. My heart was beating very fast," says Dr. Xia, 34 years old, who gave the boy an injection of adrenaline and called an ambulance. Dr. Xia says he made a critical mistake that could have killed the boy. He never checked to see if the child had an allergy to the medicine.

China has about one million rural doctors, an army of physicians who care for the country's hundreds of millions of farmers and peasants. Most of these doctors have no formal medical education and little knowledge of Western medicine or how to use it.

Now, a company called Haoyisheng.com Inc., whose name translates as Good Doctor, is teaching them the basics. Over the past four years, the Beijing-based company, which is incorporated in the Cayman Islands, has set up outlets in remote villages and small cities like Mile (pronounced Meel-eh), where local doctors attend video classes in essential matters of diagnosis and care. So far, Haoyisheng.com has outfitted 6,000 classrooms in eight provinces, with the blessing of the Chinese government, which has brought in more than 120,000 doctors to educate. The company is expanding the program to several more provinces this year.

Haoyisheng founders Mark C. Engel and Gao Zhan, who own a number of health-care businesses in China, each hold 34% stakes in Haoyisheng, while venture-capital firm Softbank China Venture Investments Ltd. owns 29% and staff hold the remaining stake. Mr. Engel, 46 years old, is the company's chairman, while Mr. Gao, 47, is chief executive, though Mr. Engel says they operate as equals.

"How frustrating must it be [for the doctors] if half the time they have people coming in and they just don't know what to do?" says Mr. Engel, an American who moved to China in the early 1990s, after which he set up a business that conducted clinical trials on the mainland for multinational pharmaceutical companies. "They've had people die on them."

Dr. Xia, one of Haoyisheng's students, learned about drug allergies only recently in the course and now knows how to test an antibiotic on the patient's skin to see if there is a reaction before giving any injections.

"In the past, it was very difficult," says Dr. Xia, who finished school when he was 17 and began practicing medicine in the village with his mother. "We would have to take a book and slowly look over the descriptions of the diseases. After consulting the book, we were maybe 50% or 60% certain the diagnosis was correct. Because my knowledge was limited, my courage was also limited."

China's government has been struggling to improve the quality of the country's ailing health-care system, which under Mao Zedong provided basic but near-universal care. That system was slowly dismantled as China began privatizing health care in the 1980s and shifted the burden of paying for doctor visits and medicines to individuals. Today, among the system's widespread failings is the erratic medicine practiced in small cities and the countryside -- a major concern of Beijing, which is increasingly sensitive to rural protests over the disproportionate prosperity of China's big cities.

China's legions of "barefoot doctors" were recruited under Mao in the 1960s and 1970s to care for the often desperately overstrained workers relegated to the countryside during the Cultural Revolution. Local officials would appoint farmers as village doctors, sending them to local hospitals for basic medical training. Even that meager education has fallen by the wayside. So the government has ordered that all of China's rural physicians earn a basic medical degree by 2010.

Mao Qunan, the spokesman for the Ministry of Health in Beijing, says the government recently acknowledged that that goal may be too ambitious. "Their skill level is not high," he says of the rural doctors. "But we need them, so we must train them." He says he is encouraged by the Haoyisheng training program's progress.

Haoyisheng.com brings the training to the doctors, who attend classes several times a week. The curriculum, which can result in a degree that satisfies the new government requirement, is based on a series of prerecorded video lectures keyed to various situations that might crop up in the clinic. The company monitors classroom attendance remotely from its office in Beijing, where the classes' answers and attendance are transmitted by the Internet.

In Mile, the fee for three years of classes is 3,400 yuan (about $448), plus 400 yuan for books. Haoyisheng receives about 1,200 yuan per student from the government. The company, which has training programs in urban areas as well as short-term courses on topics such as emergency medicine, says it had a profit of $1 million last year on revenue of $9 million.

The setup is intentionally simple, says Mr. Gao, who grew up in Shanghai and moved to Germany for a Ph.D. in biochemistry from the University of Munich. Mr. Engel says the focus of the program isn't complex medical education but "how to treat what walks in the front door."

Good Doctor has shown promising results. In a government study of 334 students who took the courses, compared with 195 who studied in traditional classrooms at hospitals, the rural doctors in the distance-learning program outperformed their urban peers when asked to make a diagnosis, answering correctly 9.38 out of 10 questions, versus 8.43 in the control group.

"It solves our problems," says Yu Huimei, the head of rural health care at the Bureau of Health in Mile, a county seat in Yunnan province that has 389 rural doctors for about 440,000 people. "The most important thing is that it's close to the place of work. It's also practical and cheap." In Mile, 160 of the 398 rural doctors are taking the course, in 19 classrooms in the county.

Pu Meilan, a Haoyisheng student, admits that for years she didn't really know how to perform cardiopulmonary resuscitation, adding that she would try pinching the person's cheeks to help the air flow to the lungs. The course taught her how to tip the patient's head back to help open the airway and let the oxygen come in. "Before, we didn't even know the meaning of 'opening the airway,'" she says.

That lesson recently came in handy. At about 3 a.m. one night in March, Dr. Pu was awakened by the husband of a woman who had gone into labor approximately eight months into her pregnancy. When the boy was born, he wasn't crying, and his skin had a bluish tint, Dr. Pu recalls. She remembers family members in the room saying that the child had no chance to live.

Dr. Pu tipped the baby's head back to help open his airway and performed artificial breathing on the infant. "The skin turned red, and you could hear the heart beating," she says. The boy survived.

Despite the progress, significant challenges remain. There is no live doctor on hand to take questions and interact with students. Christiane Horwood, the deputy director of the Centre for Rural Health in the University of KwaZulu-Natal in Durban, South Africa, runs a distance-learning program on AIDS intended mostly for nurses. The health workers work with teachers using a videoconference, but the distance learning, without live interaction, has had decidedly mixed results, she says. Not having a teacher in the room is "never the same as sitting in the same room where people can see the students and respond to them" and makes the classes "quite stilted and difficult," Dr. Horwood says. "So my experience is it hasn't been very positive. But at the end of the day, you do get that information across."

Haoyisheng is hiring doctors to assess the students in person for a few days at the end of the course, but Mr. Gao says it is "very expensive."

And not everyone is willing to participate in the course. Fan Lijin, the 29-year-old doctor who heads the health clinic in Xisan township, says that four of the 34 doctors who serve the town's 28,000 people are practicing without a license. "Sooner or later, they will be dismissed," he says.

Even licensed doctors balk at the time and money needed to complete the course. Yang Jifeng, a 50-year-old doctor in Shanzhen village, began practicing medicine in 1975 when she was 19 years old. "I think I'm too old to do that," she said during an interview at her home, which doubles as an office and has a pigsty attached to the side. "This is something for young people."

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