DR Hu Qingli knows about public health from top to bottom, from the corridors of the World Health Organization in Geneva to the outhouses of the poorest Chinese villages and leper colonies in the Philippines.

The former pediatrician and deputy director-general of WHO once trained barefoot doctors (chijiao yisheng) and led efforts to improve hygiene and fight parasite-caused snail fever in Shanghai's rural Songjiang District. He went to a remote town in Anhui Province and helped establish the first hospital, fighting officials and contractors who wanted to cut corners and save money.

Over 21 years with WHO, he traveled widely, investigating public health issues like HIV/AIDS, Ebola, mad cow disease, malaria, malnutrition, smoking control, family planning and other issues. He was posted for more than a decade in Manila.

Trailing a long list of laurels, he retired to Shanghai in 1999 where he is a consulting expert, notably in bioethics as well as public health, maternal and child health, to various universities, institutions, hospitals and organizations. He is a bioethics adviser to the Health Ministry and expert adviser to the Shanghai Health Bureau.

The 86-year-old physician has been a member for six years of UNESCO's International Bioethics Committee.

So Dr Hu knows whereof he speaks.

Market and morality

The Jiaxing (Zhejiang) native, recently spoke to Shanghai Daily in a wide-ranging interview that covered what's wrong with China's health care system, organ transplants from executed prisoners, the dangerously rising rate of Caesarian sections, failures in tobacco control, the one-child family planning policy, HIV/AIDS and other topics.

Dr Hu spoke candidly about problems in China's health care system, which starting in the 1990s underwent radical reform from a basic state-run and state-delivered system to one in which state funding to institutions was slashed and the market took over. It has resulted in dramatically higher costs, a multitude of unnecessary medications and tests, and vast differences in availability and quality of care between urban and rural areas.

Health authorities have launched a nationwide, 10-year overhaul.

Dr Hu pronounced the current system a "failure" and diagnosed the problem as marketization and commercialization caused by reduced investment by the central government. "This is the wrong direction," he said.

"The only two industries that can't introduce a market economy are education and health care," Dr Hu said. "If these two sectors are marketized, the result is clear. The wealthy people can receive good education and good health care services, while poor people have little or no access to these basic services, to which the government should offer an equal and fair access to all the people."

In 2000, WHO issued a global report on health investment and China was fourth from the bottom among all 191 members because of low investment.

"Health Ministry officials were angered by the poor ranking and even refused to participate in the meeting about the report. However, it reflected the truth ... hospitals must earn profit from prescribing medicines and offering medical tests."

Today, only 3-4 percent of state-owned hospital income comes from governmental investment; hospitals must pay for their own operations, payroll, purchases, improvement and construction.

In the 1970s, China was cited as a role model providing a basic health care system with wide coverage.

"The chijiao yisheng approach was very good, offering basic service to the large rural population in 1960s and 1970s," Dr Hu said.

In the current system anyone can go to any hospital but the doctor calls that "a completely wrong concept and huge waste of limited health care resources."

Most patients with minor ailments go to big hospitals, which are crowded with patients with chronic and other disease. But many small local hospitals have no patients, he said.

In many Western countries, most patients go first to a family doctor or primary care physician. If special treatment is required, then they see a specialist or are admitted to hospital.

"To protect doctors themselves and prepare for possible lawsuits, medical staff must arrange all types of medical tests to avoid any mistake in diagnosis," he said, acknowledging that relations between patient and doctor are often strained.

Medical staff in state-owned hospitals are underpaid and should receive a decent salary from the central government, he said, adding that doctors won't prescribe expensive and unnecessary medicines and tests if their income isn't related to hospital profit.

Organ transplants

Dr Hu criticized the government for not having a clear policy for the health care industry, saying many policies do not reflect patients' needs but instead some officials' personal views of modern medicine and Chinese tradition.

This is reflected in the huge shortage of organs for transplant and the policy of getting the vast majority of transplants from executed prisoners who are supposed to give their consent. Chinese overwhelmingly do not donate organs for transplant because it is believed the body should be buried intact. Similarly, there is resistance to recognizing brain death, while the heart is still beating - as the criterion for death. This is a major obstacle to organ transplants.

Traditional beliefs are the reason laws about brain death haven't been worked out in China, Dr Hu said. About 1.5 million Chinese need organ transplants each year but only 1 percent of patients receive them.

"A group of experts has already worked out strict regulations to evaluate brain death including three checks from expert groups and technical guidance," he said. "The entire procedure conforms to international practice."

The current definition of death as cardiac death limits transplants since organs are useless if there's no heartbeat and respiration.

Dr Hu said Vice Minister of Health Huang Jiefu, a pioneer pushing organ transplant and brain death legislation, was rebuffed by a senior health official when he planned to report on brain-death legislation and issues.

He quoted the official as telling Huang he wouldn't even listen to him if he wanted to discuss brain death.

"How can a health official have such prejudice about brain death, which is the key to promote donation and transplant - and end reliance on just-executed prisoners," Dr Hu said. China has promised that in five years it will phase out the practice of using prisoners' organs for transplant.

HIV/AIDS

Dr Hu was one of the earliest experts urging the Chinese government to seriously tackle HIV/AIDS.

The Joint UN Program on HIV/AIDS was established in 1995 by WHO and other UN agencies, while Dr Hu was WHO's deputy director-general overseeing global HIV/AIDS control.

He urged China to act fast to stop the spread of AIDS, urging officials to learn from Africa where HIV/AIDS spread along highways because long-distance truckers visited prostitutes and then infected their wives and other women.

At that time China was expanding its highway network and the disease spread just as Dr Hu had predicted.

When the illegal blood sales business in Henan Province was exposed in the late 1990s, Dr Hu returned to China and visited the Ministry of Health, urging immediate investigation into the whereabouts of infected plasma, which found its way into hospitals.

Poor farmers had sold their blood and plasma in unhygienic, for-profit collection centers where syringes, tubing and other materials were not disposable.

Dr Hu said he became enraged after a vice minister told him that the investigation failed since local governments tried to cover up the scandal.

"Though illegal blood sales occurred in Henan, the Health Ministry should shoulder some responsibility," he said.

Years later, Dr Hu was proved correct. The scale of the blood disaster in Central China was vast; the issue of AIDS and tainted blood was taken seriously.

"It could be more effective if measures were launched earlier," he said.

Dr Hu was critical of the family planning policy, which limits most urban couples to one child. He said the policy indeed limited population growth but caused other problems, such as unbalanced population structure. The population is aging rapidly, the young working age population is becoming insufficient and males seriously outnumber females. Young single-children face a huge problem caring for elderly parents and the health care system is burdened.

He called a one-child environment bad for children's emotional and moral development.

The policy launched in the 1970s was supposed to be temporary, he said.

Too many C-sections

Dr Hu worries about the extremely high rate of Caesarian sections in China, which has the world's highest rate.

In 2010 WHO reported China's C-section rate at 46 percent; WHO says 10-15 percent should be the upper limit for the abdominal surgery. The Asian average is 27.3 percent.

"Such a high C-section rate is not reasonable. Many surgeries are not indicated medically," Dr Hu said. "It's harmful for women and not good for the health of the newborn baby."

Shanghai's C-section rate was 53.6 percent in 2010 and rising, says the Shanghai Women's Health Institute.

C-sections are supposed to be used only if the health of the mother or infant is at risk from natural childbirth.

More women should be educated about C-section risks, Dr Hu said, adding that doctors also recommend C-sections because labor is time-consuming and they want to avoid medical disputes and lawsuits arising from protracted natural birth, which also carries some risk.

China's tobacco control have largely failed because authorities focus overwhelmingly on tax income from the tobacco industry, while ignoring future health problems, Dr Hu said.

He noted that Health Minister Chen Zhu recently suggested raising tobacco taxes to improve smoking control "but some officials criticized the idea."

He praised the approach in Australia, which invests tobacco tax directly into the health care industry, since that income will finance care for patients with smoking-related health problems.

Born in 1932 in Jiaxing, Zhejiang Province, Dr Hu graduated from Shanghai Medical College (now the school of medicine of Fudan University). From 1956-78 he practiced pediatrics at Guang-Ci Hospital (now Ruijin Hospital).

He studied in the UK from 1966-67, when all Chinese students were recalled home in the "cultural revolution" (1966-76). Dr Hu was targeted as an intellectual and ordered to teach rudimentary health care to barefoot doctors and lead control of water-borne parasites in Songiang County at that time.

In 1969 he was sent to Anhui Province to oversee construction of a 300-bed hospital. He planned from scratch and wasn't afraid to battle senior officials who wanted to cut corners. He insisted patients' toilets be built inside the main structure, not outside, as officials wanted. He opposed use of cheaper, permeable ceramic tiles in the operating theater and insisted on non-permeable materials that could be easily cleaned.

"My deepest impressions were my arguments with senior officials about the location of toilets and the design of the operating theater," Dr Hu recalled.

"I've never complained about tough tasks and changes in my career. Any efforts will be useful and my experiences working in Songjiang and Anhui were very helpful to me at WHO," he said.

Dr Hu returned to Ruijin Hospital, practicing pediatrics, in 1971, and would go on to become an international civil servant dedicated to health care.