Shortly after arriving in the Middle Kingdom, I became aware of a Western expat in town who had a very frightening story to tell of his hospital experience after having fallen and broken his arm. While he was satisfied with the way his arm eventually healed, he related a very disturbing story of how his Chinese doctors refused to provide him with any pain medication after resetting his fracture. He explained the excruciating pain he was in for a couple of days and how he wasn't able to go to work or even sleep for several days and nights until the swelling and pain eventually subsided on their own. Quite frankly, I had difficulty even imagining this particular case scenario until I needed surgery myself several years later.
I had developed a sebaceous cyst that, although could have been left alone, was bothersome enough for me to consider having it surgically removed. As the cyst was in a very sensitive area and as I anticipated having at least some discomfort after the procedure, I brought up the issue of pain medication, remembering quite clearly the nightmarish story I had been told years earlier. The physician's response was immediate and clearly well-practiced: "You won't need any pain medication." I, of course, had a different opinion on the matter and, after what amounted to a lengthy negotiation, the physician finally but reluctantly agreed to prescribe a pain medication that he promised would be more than sufficient. I don't recall the name of the medication now but do remember that it was most definitely not an opiate derivative (nor, as it turned out, was a stronger medication necessary).
China is a country obsessed with the fear of addiction. I would later learn that Chinese medical students are repeatedly admonished throughout their training against prescribing any medications with a known potential for abuse and dependency, especially opiate derivatives and benzodiazepines (minor tranquilizers). The Chinese medical community is so strongly aligned against prescribing pain medication, irrespective of actual need, that I now spend an entire class in my Medical Ethics course reviewing the infamous 1973 Donald "Dax" Cowart case and engaging in my own proselytism about how grossly unethical, perhaps even criminal (by today's standards), Cowart's doctors were for not only treating him against his will but allowing him to suffer in unimaginable pain for 14 months.
Unfortunately, Chinese physicians are engaging in the same type of unethical behavior some 37 years later. While China's Ministry of Health officially adopted a Chinese version of the WHO's three-step analgesic ladder for the relief of cancer pain in 1995, one recent journal article confirms that there is a great deal of resistance to it in practice (Liu, et al., 2007). Chinese physicians are both culturally and professionally reticent to prescribe opiate-based pain medications even to patients who are writhing in agonizing pain from the terminal stages of cancer.
In the context of China's Opium Wars of the 19th century and the estimated 20 million people who were addicted to opioids at the founding of the People's Republic in 1949 (Feuerberg, 2008), this fear is understandable. It is perhaps even more understandable when you consider that at least one report places the number of current opium addicts at as many as 5 million, compared to an estimated 1 million addicts in the United States, at only about one-fourth of China's population (ibid; Lloyd, 2003).
While China's national fear of addiction is understandable, the country's response to it is a rather disturbing one. According to a very recent report by The Epoch Times, addicts are "sentenced" to a two-year mandatory term at facilities that are run no differently than were the Reeducation Through Labor (RTL) camps. Inmates are compelled to work up to 18 hours a day, without pay, and are denied basic health care (Feuerberg, 2010).
In other words, China's response to addiction is primarily (if not only) a punitive one. Perhaps this response can also be regarded as understandable in that people typically hate and strike out against what they fear the most. In light of the aforementioned Opium Wars, for the Chinese government regime, addiction of any kind is tantamount to submission to Western control and supremacy and, therefore, must be eliminated at all costs.
China's punitive response to addiction is perhaps predictable when you consider it in the broader context of the country's current mental healthcare system. Seeking professional help for one's emotional and personal problems is still highly stigmatized in China, as it was in the United States up until the 1970s (where now it is regarded as a privilege of the middle class and psychologically-sophisticated parents set aside savings for their child's future psychoanalysis along with college tuition).
Even if one is courageous or desperate enough to rise above society's strong prohibition against seeking help for emotional problems in China, finding adequate care is no easy feat, especially outside of Shanghai and Beijing. It is reported that China has only 14,000 qualified psychiatrists and 17,000 psychologists (certified at the bachelor's level), which is about 10% of what developed countries have (Sparks, 2008).
The other significant problem with these tremendous fears of addiction, dependency (of any kind), not to mention "emotional weakness" is that fear begets more fear and eventually mass hysteria. Chinese psychiatrists have distinguished themselves as being the very first in the world to register "Internet Addiction" as a diagnosable mental illness with the World Health Organization (Macartney, 2008).
However, at least one news report indicates that conditions at these Internet addiction rehabilitation centers are not significantly different than those reported at the "drug treatment" facilities (Adams, 2009) and London's Telegraph recently reported how one teenage boy was actually beaten to death during his detention in a one-month Internet addiction rehab program, at a treatment cost of 7,000 yuan per month (Moore, 2009). I'm waiting to read reports of the grand opening of China's first "mobile phone addiction" treatment center.
All of this, of course, raises the basic question: What is an addiction? Tao Ran, a Chinese psychologist who runs one of these Internet addiction boot camps, defines an Internet addict as "anyone who spends more than six hours per day for three months or more on non-work- or study-related Internet use" (Adams, 2009). By this very limited definition, I could arguably be categorized as an Internet addict in China, depending entirely on how you define "study- or work-related." (Or maybe I'm just a "computer addict"--I'll have to check my watch more carefully next time.)
The problem with relying upon quantifiable criteria exclusively, in regard to addiction, at least from a Western mental health perspective, is that it completely fails to take into account any consequences of the behaviors in question. For example, what is the difference between a heavy drinker and an alcoholic, an industrious employee and a workaholic, or a woman who loves to shop and a shopaholic?
The real answer is not one of degree but effect. According to the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) of the American Psychiatric Association, a diagnosis of an addictive disorder, especially in the absence of physiological dependence, can only be made if the practitioner can document "clinically significant distress or impairment in social, occupational, or other important areas of functioning" (APA, 1994, p. 213).
Of course, the question of impairment in social functioning is entirely relative and something of a hornet's nest I think. The difference between a husband who enjoys pornography on occasion and a "sex addict" may have everything to do with the sensibilities of the woman he just happens to be married to and very little or nothing to do with the questionable behavior itself. The difference between a Warcraft enthusiast and an Internet addict, depending on how we are defining impairment in social functioning, may have little or nothing to do with the student's grades or peer relationships and everything to do with how urbanized, Westernized, and relatively young one's Chinese parents are. While alcohol and drug dependencies are relatively easy to document, repetitive behaviors that are not associated with physiological addiction are much trickier to diagnose as "addictive" and doing so is often strictly a matter of social context and professional opinion.
Hopefully as China continues to become more economically powerful and Westernized, it will heal from the wounds of its past and adopt kinder and gentler views on the treatment of mental and emotional disorders, including addiction. While it is certainly true that all physicians have a duty to do no harm, such that indiscriminate use of opiates is often ultimately harmful, they also have an ethical obligation to attend to the palliative needs of all their patients.
In the meantime, if you ever need surgery in China, make absolutely certain that you negotiate upfront for appropriate pain medication.
Adams, Jonathan (2009, January 6). In an increasingly wired China, rehab for Internet addicts. Christian Science Monitor. Retrieved March 20, 2010 from http://www.csmonitor.com/World/Asia-Pacific/2009/0106/p01s03-woap.html
American Psychiatric Association (1994). The Diagnostic and Statistical Manual, Fourth Edition. APA: Washington, D.C.
Feuerberg, Gary (2010, Jan 19). Human Rights Watch: ’Compulsory Drug Detention Centers’ in China. The Epoch Times. Retrieved March 21, 2010 from http://www.theepochtimes.com/n2/content/view/28228/.
Liu, W., Luo, A. and Liu, H. (2007, September). Overcoming the barriers in pain control: an update of pain management in China. European Journal of Pain Supplements. Vol 1, Issue 1.
Lloyd, Jennifer (2003, June). Heroin. Almanac of Policy Issues. Office of National Drug Control Policy. Retrieved March 20, 2010 from http://www.policyalmanac.org/crime/archive/heroin.shtml
Macartney, Jane (2008, November 11). Internet addiction made an official disorder in China. Times Online. Retrieved March 20, 2010 from http://www.timesonline.co.uk/tol/news/world/asia/article5125324.ece
Moore, Malcolm (2009, August 4). Chinese internet addict 'beaten to death' . Telegraph. Retrieved March 20, 2010 from http://www.telegraph.co.uk/news/worldnews/asia/china/5973301/Chinese-internet-addict-beaten-to-death.html
Sparks, Alicia (2008, August 8). Mental Health Abroad: Spotlight On China. Retrieved March 4, 2009 from http://www.mentalhealthnotes.com/2008/08/08/mental-health-abroad-spotlight-on-china/.