Ai Pandemic and Healthcare 1St Edition Nuoya Chen Online Ebook Texxtbook Full Chapter PDF
Ai Pandemic and Healthcare 1St Edition Nuoya Chen Online Ebook Texxtbook Full Chapter PDF
Ai Pandemic and Healthcare 1St Edition Nuoya Chen Online Ebook Texxtbook Full Chapter PDF
Nuoya Chen
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Nuoya Chen
Former HEART-ITN Project
University of Macerata
Macerata, Italy
p,
p,
A SCIENCE PUBLISHERS BOOK
A SCIENCE PUBLISHERS BOOK
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1
According to CDC, “long-COVID” is broadly defined as signs, symptoms, and conditions that
continue or develop after acute COVID-19 infection.
iv AI, Pandemic and Healthcare
at reducing the stress for doctors in their daily work and promoting
diagnosis, treatment and recovery efficiency for patients.
This book addresses the challenges towards implementing telehealth
solutions in Europe and China. Currently, there is limited use of AI to
solve healthcare related problems, due to limitations such as lack of
quality data, data interoperability issues and lack of a tangible business
model. The author tries to address the challenge for the implementation
of telehealth solutions by determining the demand of telehealth solutions
in the selected European economies and China (Chapter 1), analyzing the
emerging business models for telehealth solution ecosystems in China
(Chapter 2), and answering the questions as to how AI will change the
scenery for healthcare in the post-Covid 19 world (Chapter 3) and how
COVID 19 may change the perspective for each stakeholder when it comes
to telehealth solutions (Chapter 4).
Chapter 1 and Chapter 2 form the theoretical background for the
empirical work in Chapter 3 and Chapter 4. The book addresses four
research questions, namely “Which societal and social-economic unmet
needs can Internet of Healthcare Things help to resolve?”, “What are the
business models innovated for tech companies in China for the smart
health industry?”, “What are the facilitators and hurdles for implementing
telehealth solutions in the post-Covid world?”, and “Have stakeholders
changed their perspectives regarding the use of telehealth solutions?”
Both qualitative study and quantitative analysis have been performed
based on data collected by in depth interviews with stakeholders, and
focus group study with potential users (rural and urban residents in
Beijing) for telehealth solutions.
The digital platform framework has been used in Chapter 2 as the
theoretical framework. Chapter 3 presented a summary of the institutional
stakeholder interviews with the interview notes attached whereas Chapter 4
summarizes the focus group study results with individual user interviews.
Telehealth solutions have a great potential to fill in the gap for lack
of community healthcare and ensuring health continuity between the
home care setting, community healthcare and hospitals. There is a strong
demand for such solutions if they can prove the medical value in managing
chronic diseases by raising health awareness and lowering health risks
by changing the patients’ lifestyle. Analyzing how to realize the value of
preventive healthcare by proving the health-economic value of digital
health solutions (telehealth solutions) is the focus of this research.
Several hurdles still remain in the path to building trust towards
telehealth solutions and using AI in healthcare. The next step in this
research can also be extended to addressing such challenges by analyzing
how the transparency of algorithms can be improved by disclosing the
data source and how the algorithms were built. Further research can be
done on data interoperability between the EHR systems and telehealth
Preface v
Preface iii
Index 191
Chapter 1
Telehealth Solution Market
Demands in China and in
Europe (Germany, Denmark
and Italy)
1. Introduction
The pandemic has changed the perspective of the healthcare community
towards digital healthcare services. Before the pandemic, digital
healthcare was seen as an alternative for traditional in-person meetings
between doctors and patients. It is difficult to convince insurance
companies, governments and users of telehealth solutions to trust digital
healthcare solutions. After the pandemic, more funding, investments and
attention are flowing into the field of IoT and healthcare, driving rapid
developments in the healthcare industry into the Web 4.0 era (Lepore
et al. 2022).
Healthcare can be costly and inefficient in different stages—from
diagnosis to treatment, or from prevention to care at home. With the
population aging in Europe and in China, rising healthcare costs and
lack of efficient healthcare solutions are posing challenges for the society.
The COVID-19 pandemic has drained the healthcare resources from
local healthcare facilities, with healthcare resources concentrated on
pandemic control and prevention. The consequences are destroying the
pre-pandemic healthcare service structure and have offered a rare chance
for digital healthcare service providers. Meanwhile, for patients, the
waiting time for healthcare services are longer, costs are higher, suggesting
an unsustainable healthcare management system.
Meanwhile, AI has evolved to a degree where much more data is
required to generate meaningful insights. Healthcare AI has progressed
2 AI, Pandemic and Healthcare
Telehealth now has the capability to democratize healthcare for the first
time in history (Standford Medicine 2018). The transformation happens on
two levels, namely the distribution of data and the ability to generate and
apply insights at scale. It equips patients with data, technology and access
to expertise, thereby empowering them to manage their own health. On
the institutional level, the transformation brought by telehealth solutions
essentially means less focus on routine tasks and more energy for the
areas creating the most value and satisfaction (Standford Medicine 2018).
To sum up, the ubiquitous use of mobile telehealth devices, the
maturation of health information transfer standards and accessible
healthcare-related software have been contributing to personalizing
healthcare records. Despite the great potential of connected devices, the
capability of telehealth solutions to improve patient outcome, reduce cost
and improve healthcare efficiency remains debatable (Dameff et al. 2019).
In the stage of adoption of electronic patient health records, systems have
shown great enthusiasm. Direct patient-facing technology continuously
developed by mature technology companies and well-established research
institutions suggest that the digital healthcare landscape may be sufficient
to trigger wide adoption of smart health solutions (Dameff et al. 2019).
Examples of such solutions include the algorithms detecting early signals
of kidney failure, developed by Deep Mind and Google Health (FT 2019);
the early detection algorithms for breast cancer, developed by MIT (MIT
2019); and the Neuralink brain implant designed for people with brain
and spinal injuries or congenital defects such as Parkinson’s disease (The
Guardian 2019); all of these solutions have boosted significant scientific
and business interests. Meanwhile, the wide adoption of smartphones,
the upgraded communication standards, and the availability of software,
hardware and sensors also lay the foundation for such technological leaps
with AI applications in healthcare (Dameff et al. 2019). It takes time to
observe the long-term benefits of AI in healthcare in terms of quality
improvement, cost reduction and patient outcomes; yet the enthusiasm
of early adopters has suggested the potential benefits of adopting smart
health solutions.
Despite heavy investments made by the government as well as the
private sector in telehealth solutions in the U.S., Europe and China,
embedding IoT in different stages of healthcare is an ongoing process. It is
challenging for the medical community to make use of the large amounts
of data generated by IoT devices (Deloitte 2018). Most physicians even
find it difficult to interpret the data presented by wearables and generate
valuable insights (Schnall et al. 2016).
Algorithms may be powerful, yet utilizing AI to identify useful
information from redundant data and to improve accuracy in identification
and prediction with limited amount of training data in the clinical setting
is challenging (Minor 2018). Realizing population health management
Aging Led Demand for Telehealth Solutions in Europe and in China 5
2. Research Methodology
Primarily, qualitative study has been used in the paper for parts three,
four and five; quantitative analysis has been used to describe the market
features and consumer preferences in Europe and in China over healthcare
and lifestyle choices. Secondary data has been used in this case for the
study. To compare the quality of healthcare in China and Europe, key
indicators such as insurance coverage, leading causes of death, and life
expectancy in Denmark, Germany, Italy, rural China and urban China
have been used.
China is a diverse country with different public health situations in
rural and urban areas. Urban residents in Tier-1 cities enjoy better medical
resources, including a concentration of high-quality hospitals, doctors
6 AI, Pandemic and Healthcare
Table 1.1: World’s Top Five Wearable Brands (by shipment) and their health/well-being-
related functions; Source: Apple 2019, Xiaomi 2019, Fitbit 2019, Huawei 2018, Garmin 2019.
for hospitals (Stanford Medicine 2018). Smart health solutions can also
deliver faster and more precise diagnosis, and reduce burn out risks for
physicians with AI assistants providing advice regarding image reading,
diagnosis and prescription.
Artificial intelligence has shown great promise in clinical areas such
as diabetes, heart disease, cancer, neurological disease, etc. (Rahman et al.
2021). AI has been projected to reduce the cost for healthcare in the United
States by $150 billion by 2026 (Accenture 2018, Stanford Medicine 2018).
The most valuable new developments herein have been predicted to be
robot-assisted surgeries, with a projected economic value of $40 billion.
The next most valuable development is virtual nursing assistance, with
a projected economic value of $20 billion, and the third most valuable
development is administrative work-flow assistance, with a projected
economic value of $18 billion (Accenture 2018, Stanford Medicine 2018).
Telehealth solutions provide the prospect of establishing a systematic
data processing system to cover each stage of healthcare to perform
preventive healthcare tasks. Telehealth devices can perform real-time
and synchronized monitoring of biometric and environmental indicators,
including temperature, humidity, luminosity and acoustic noises.
With the systematic monitoring of human body and its interaction
with environment, it is possible to analyze the correlations between the
environment and the bio-signals (Rinbeat 2018). Systematic monitoring
across a large population can help scientists to recognize significant
trends and patterns related to human health and develop algorithms.
These algorithms can potentially predict the users’ stress and well-
being, emotions, cardiopathies, discomfort level, quality of sleep, sports
performance and recovery time, attention capacities and concentration
level, etc. (Rinbeat 2018).
Ultimately, wide applications of AI and IoT in health, fitness,
military, automotive industry, transportation and insurance may emerge.
For instance, for military purposes, fitness trackers combined with
environmental sensors can help soldiers in predicting attention capacities
and adjusting stress levels, hence adapting to war situations. In the field of
sports, the system will be able to enhance sports performances, calculate
recovery time and evaluate the level of discomfort for users. When it comes
to healthcare, the system has the capacity to perform real-time monitoring
of the heart and the central autonomic system (Rinbeat 2018).
With healthcare costs on the rise, Internet of Healthcare Things can
help in curbing this trend by preventing diseases and promoting a healthy
lifestyle. Expenditure on preventive healthcare has long been but a small
part of the entire healthcare system; most of the spending is focused on
acute and extreme conditions. Internet of Healthcare Things can potentially
detect early symptoms of complex conditions such as breast cancer
(MIT 2019, Ehteshami Bejnordi et al. 2017). Wearables, by monitoring vital
10 AI, Pandemic and Healthcare
Service
Companies Wearables App Mobile Medical Self-Cloud Online AI Smart Home Internet M&A Data
Payment Service Computing Medical Appliances Appliances- Hospital/ related to/ Interoperability
for and Platform for Education/ in Hardware Investment Association standards
Hardware Wearable App Hospital Cloud Computing AI Smart Home Connected Data Interoperability
used Medical Platform for Appliances Appliances- Hospitals standards
Equipment Developers in Diagnosis Hardware consultation
Huawei X X X X X
Xiaomi X X X
Simens X X X X
Philips X X X X
GE X X X X
Mindray X X X
Aging Led Demand for Telehealth Solutions in Europe and in China 13
when most laptops no longer carry a CD reader. Hospitals still use fax
to share patient records (Stanford 2018). In China, patients usually pay
US $0.5 for a blue paper book where the doctors record notes. Patients then
get the X-Ray or MRI images printed out and taken away; most patient
records are stored in separate electronic health record systems at different
hospitals. EHR records are static and usually stay within the institutions
that collect them; EHR data stored in different systems creates the
interoperability problem. Hospitals generally have no exact standards on
the type of data input in the EHR system, with each individual physician
and department entering data according to their own preferences. This
brings disparity and differences in the quality for EHR stored (Stanford
Medicine 2018). For some reason, hospitals see the data of patients as their
own assets, often refusing requests from patients to transfer data between
organizations.
For patients with chronic diseases, it is difficult to consult with different
levels of healthcare service providers with scattered medical records at
different medical institutions. There is a great interest among patients to
access information from hospital records and carry convenient, patient-
controlled portable records. Personal health records are distinct from
electronic patient records maintained by the health care system patient
portals—personal health records are deposits of clinical data managed by
patients (Bates and Wells 2012). These records may contain the same types
of data as in hospital maintained medical records (such as medical history,
diagnostic test results and clinician documentation) (Dameff et al. 2019).
Telehealth solutions offer a change to patients for such services.
Doctors, on the other hand, find EHR input a large part of their daily
routine. A study conducted by Stanford Medical School confirmed that
EHR inputs contributed to burn out in physicians and has stood in the
way of doctor-patient communication (Stanford Medicine 2018). 44% of all
physicians surveyed said that the primary purpose of EHR is data storage,
with 8% of physicians citing medical factors related to EHR (Stanford
Medicine 2018). One third of all the physicians surveyed expressed hopes
for financial information to be integrated in the system so that patients
would be able to weigh their cost options; the primary concern is still the
interoperability problem, where data can become available for all parts of
healthcare systems.
Health Level Seven International (HL7.org)1 has developed Fast
Healthcare Interoperability Resources (FHIR), offering a standard data
1
Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards
developing organization dedicated to providing a comprehensive framework and
related standards for the exchange, integration, sharing, and retrieval of electronic health
information that supports clinical practice and the management, delivery and evaluation
of health services, available at: http://www.hl7.org/about/index.cfm?ref=nav, last accessed
on September 2nd 2019.
14 AI, Pandemic and Healthcare
Supply
Business modes,
models,
technological
• Technologies Demand
interfaces, open- • Infrastructures Organizations
financing,
source platforms for • International Standards education and
developers,
manufacturers, expertise, hospitals,
suppliers and sub- general practitioners,
contractors municipalities
For instance, in China, the waiting time mainly occurs at the hospital
reception and the admissions window, and between the appointment time
and the time at which patients are attended by doctors (Sun et al. 2017).
Usually, Chinese patients need to endure long waiting times in hospitals
for registration, check-ups and payment; the observable change with
telehealth solutions is a significant reduction in waiting time for treatment.
The mobile payment and patient registration system connected to Wechat,
a popular Chinese social medial software available for smartphones and
computers, with more than 1 billion users (Forbes 2018), has significantly
lowered the waiting time for patients and promoted accessible healthcare
(Forbes 2014).
The mobile payment system has integrated patient registration,
payment, and prescription distribution services. With Wechat, more than
13,300 hospitals now allow patients to pay with their mobile devices; more
than 22,800 hospitals offer an online appointment system, and more than
38,000 hospitals publish healthcare related information via Wechat public
accounts (Shen 2020, McKinsey 2019).
Wearables with heart rate monitoring functions make it possible for
patients with potential cardiovascular diseases to get prompt treatment.
Recently, a patient with intermittent palpitations in his 70s observed
paroxysms of tachycardia at rest on his fitness tracker. The patient then
purchased an AliveCor Kardia device approved by the US Food and Drug
Administration (FDA) to get single-channel electrocardiographic images
on his smart phone. He recorded the irregular heartbeats with retrograde
P waves. The patient’s self-diagnosis was confirmed by subsequent
12 lead electrocardiographic recordings and he received an appropriate
treatment (lp, JAMA 2019). The newest model of Apple Watch is able
to generate electrocardiographic recordings with the back and the bezel
of the watch serving as lead I electrocardiographic bi-poles (lp, JAMA
2019). Apple Watch 4 is designed to detect occult atrial fibrillation (AF)
(Apple 2018). Wearables now have the potential to improve the diagnosis
of cardiovascular diseases such as sporadic or occult AF. However, it
remains challenging for physicians to analyze and interpret the information
provided by the smart devices of patients. The reason is that the devices
may generate false alarms and result in unnecessary further testing for the
patients; one recent study involving 100 patients with cardiovascular AF
conditions showed that the device’s algorithm categorized 34 percent of
all recordings as unclassified even under direct observation (Bumgarner
et al. 2018b). Applying diagnosis based on recordings generated by smart
devices poses the risks of misinterpretation and inappropriate results,
which can be problematic if devices are used in a population with low
prevalence of diseases.
To summarize, telehealth solutions bear a huge market value and
a great potential to improve efficiency and save costs in each stage
18 AI, Pandemic and Healthcare
Figure 1.2: Age dependency ratio (old) in the European Union and China, 1960–2021.
Source: World Bank 2022.
Figure 1.3: Healthcare expenditures per capita in Germany (top), Italy (middle) and
Denmark (bottom), 2012–2016. Source: Eurostat 2021.
Figure 1.4: Life Expectancy in Germany, Denmark and Italy, along with the EU average.
Source: World Bank 2022.
demand from the population, policy makers in Europe are trying to find
a way to improve healthcare quality while taking control of healthcare
budgets. Several European countries are trying to implement the value-
based healthcare system, in an attempt to look at the healthcare system as
a whole. However, there are several challenges in the implementation of
the value-based healthcare model: (a) lack of detailed data on healthcare
outcomes across the care cycle, (b) growing pressure for new pricing
models, especially in terms of medications and medical devices, (c) need
for mechanisms to ensure that the most vulnerable group of the society
also has access to healthcare (Economist Intelligence Unit 2016). So far
in Europe, there have been many pilot programs running at individual
healthcare institutions for value-based healthcare models; there has also
been greater focus on their effects on the spending on pharmaceutical and
technology by the general population. There is even greater collaboration
for developing the European Network for Assessing Health Technology
Assessment for better evaluation of the cost effectiveness, for policy
makers to make precise decisions (Economist Intelligence Unit 2016).
There is also a need to improve government-industry collaboration to
maximize the value of investments in health technologies. Furthermore,
there is a need to ensure accessibility of the healthcare system, a problem
for countries with weak primary level healthcare.
22 AI, Pandemic and Healthcare
4.1.1 Demark
The Danish healthcare system has traditionally led the European digital healthcare
scene in the level of digitalization, the efficiency of the healthcare system, and
healthcare cost reimbursement. In such an open market, the Danish healthcare
system is one which welcomes external technology. In 2018, the Danish
government carried out a 4-year plan to implement better digital healthcare
strategy. The plan projects that the population over 75 years old is growing and
will double in the next 30 years—from 9.8% to 14.4%. The plan analyzes the
tendency of the elderly to use internet—by 2016, 86% of all elderly users have
become internet users.
The Danish healthcare system operates with three administrative
levels—national, provincial, and local. The state is in charge of regulatory
and supervisory functions; the five regional administrative care systems
are responsible for hospitals, GPs and psychic care. The municipalities
take care of a number of general practitioner services and elderly care
(Ministry of Health Danmark 2017). Normally, all healthcare services
are paid by general taxes and are supported by the central government’s
grant, reimbursement and equalization schemes. Public finance provides
84 percent of all healthcare expenditures, while the rest 16 percent was
funded through patient co-payment schemes in 2015. Healthcare costs
accounted for 30 percent of the total public expenditures and 10.6 percent
of GDP in 2015, which is higher than the average 9 percent of GDP in
OECD countries (Ministry of Health Danmark 2017).
All residents in Denmark have access to healthcare, with most of the
services offered for free. National legislation ensures that diagnosis and
treatment are offered within certain time limits and patients have the right
to a free choice for hospitals. Residents in Denmark may also seek treatment
from abroad if treatment has not been offered in Denmark, upon approval;
Aging Led Demand for Telehealth Solutions in Europe and in China 23
Figure 1.5: Danish Health Care system structure. Source: Ministry of Health Denmark 2017.
24 AI, Pandemic and Healthcare
4.1.2 Germany
To facilitate the use of telehealth solutions and improve the efficiency of the
telehealth solution approval process, the German government has introduced new
regulations and laws. For instance, the digital healthcare act will allow the statutory
insurance companies to be able to reimburse patients for home-use IoT medical
devices (Stern et al. 2022). The ‘fast track’ allows low-risk medical devices mainly
used by patients at home to get regulatory approval relatively faster. The German
Federal Agency for Drugs and Medical Devices (BfArM), by deploying the fast-
track approval process for home-use medical devices, strengthens the use of real-
world data (real world evidence) to improve data interoperability, privacy and
quality of services and solutions offered by medical device providers. Real world
evidence is collected through patient reported feedbacks on treatment outcome
and user experience. The available funding for digital healthcare solutions has
increased exponentially to Euro 3 billion by Bundestag and Euro 1.3 billion by
local German governments (Lovell 2019).
The German regulators learned from the FDA to use real world
evidence for the approval of medical devices, thereby lowering the cost for
tech companies, large or small, to bring digital healthcare devices from the
lab to the market. The Digital Healthcare Act also aims to lower the barrier
to entry for digital healthcare startups, creating more opportunities for
SMEs to enter the market. Needless to say, the Digital Healthcare Act has
a strong relationship with how the German healthcare system works and
functions.
The German healthcare system is characterized by universal coverage
of insurance for a wide range of services (Busse et al. 2014). The system
holds a strong solidarity principle whereby treatment is offered regardless
of financial status of the patients or the premium paid and the morbidity
risks (Ridic et al. 2012, GKV 2019); the principle of benefits ensures benefits
without any up-front payment for the insured residents; such residents
are also free to choose the services and insurance plan service providers
(GKV 2019). The system offers a network of excellent service providers,
both private and public. The ‘Bismarck’ model of social insurance system
has extended sick benefits to all low wage workers since 1871. After
the reunification of Germany, all 16 provinces (“Laender”) have had an
independent healthcare policy to a large extent.
All citizens in Germany are now required by law to have health
insurance, with more than 90 percent of the population covered by the
state statutory insurance system. The rest 10 percent are covered by
private insurance or government schemes for students, police force
or special assistance. Only those with an annual income of more than
576,000 Euros are entitled to choose private insurance. The state insurance
funds are formed through contributions from both the employers and
employees; the uniform contribution rate for all insured was introduced on
Aging Led Demand for Telehealth Solutions in Europe and in China 27
Figure 1.6: Healthcare expenditures as percentage of GDP for the selected EU countries and OECD
member states. Source: World Bank 2018.
Figure 1.7: Major Statutory Insurance spending in Germany (from top to bottom: Hospitals, Drugs,
Physicians, Dentists), 2000–2010. Source: Obermann 2013.
Figure 1.8: Stakeholders in the German Healthcare System for implementing e-Health
solutions. Source: Obermann et al. 2013.
4.1.3 Italy
Italy is an interesting case for this study, given the north-south differences
in the economic development level and thus diversification of health
service quality. The Italian health system is decentralized to a large extent,
with most regions managing the organization of healthcare; the national
level has a limited amount of power (Cicchetti and Gasbarrini 2016). The
state has full control of the core benefit package, but evidence shows that
the service quality varies greatly across regions (Cicchetti and Gasbarrini
2016). The Italian national health service (NHS) is organized at national,
regional and local levels (European Commission 2017). The Ministry of
Health takes a stewardship role in the healthcare system, determining
the core benefits packages and allocating budgets to regions (Cicchetti
and Gasbarrini 2016). The regional healthcare authority is responsible for
delivering community healthcare, primary care, and specialist care with
physicians or public hospitals or approved private practices (Cicchetti and
Gasbarrini 2016).
The decentralization is based on the idea that localization can be
the best option to meet local healthcare needs (Cicchetti and Gasbarrini
2016); Due to decentralization policies, different regions show a large
divergence in terms of public resources available for healthcare because of
differences in economic development, as well as regional infrastructure.
Traditionally, northern Italy, which is more industrialized than Southern
Italy, have better healthcare services for residents. For instance, the
northern and the central regions have higher healthcare capacity, more
advanced technology and better perceived quality of care compared to
the southern region. In the end, patients flow from the south to the north
for better treatment. Almost 30,000 patients leave the area of Campania,
Calabria and Sicily per year for better quality of care in the north (Ministry
of Health Italy 2011). The healthcare spending in southern regions, such as
Campania, was over 40 percent less than the national average spending on
health in 2016 (Ministero dell’Economia e delle Finanze 2020, Istat 2017).
After the financial crisis of 2008, there have been calls to recentralize the
healthcare system. As a result, half of the regions report deficit in the
health sector (European Commission 2017).
Compared to other European countries, the out-of-pocket spending
ratio for Italian residents is high, even though the Italian healthcare system
provides universal healthcare coverage to those with a residence permit
(European Commission 2017). 23 percent of healthcare expenditures in
Italy are paid out of pocket, compared to EU average of 15 percent in
2015. Primary and inpatient care are free, while co-payment is applicable
32 AI, Pandemic and Healthcare
Figure 1.9: Out of pocket payment expenditure in current health expenditures (in %).
Source: World Bank 2022.
Figure 1.10: Age dependency ratio (Old) in Italy and the European Union.
Source: World Bank 2022.
Plan 2012, which aims at developing online solutions and EHR systems,
and offering an e-prescription system for patients. The impacts of these
initiatives are yet to be evaluated (Ferré et al. 2014).
and outpatient care for the same reason that most medical resources, such
as qualified doctors, advanced medical devices and useful medication can
only be found in ‘Tertiary Level Hospitals’. Both rural and urban patients
in China have the incentive to go to level three hospitals for diseases
ranging from flu to cancer. This has resulted in overused and burdensome
hospitals and insufficient use of primary care centers and other primary
care facilities. Table 1.4.1 describes the utilization rate of all levels of
hospitals in China in Year 2021.
Compared to 2017 (see Table 1.4.2), in 2021, the number of hospitals
grew in China, while the bed utilization rate as well as the number of
outpatients and inpatients dropped for level II and level I hospitals (not for
Level III hospitals). Considering the impact of Covid and the zero-Covid
policy, it is evident that access to healthcare services has deteriorated
during the Covid time, while healthcare cost has risen. Hospitals, which
are financially independent from one another, pass on the cost to the
patients. Compared to Level III hospitals, the number of outpatients and
inpatients for level II and level I hospitals has dropped significantly; the
outpatient number for level III hospitals also declined by 0.62 billion.
It is noticeable that the number of Level III hospitals and the number of
outpatient treatment are not proportional. This explains the long waiting
times at hospitals and the patients’ complaints of poor services received,
including seeing doctors for merely 2 minutes after a waiting time of half
an hour (Lim 2014).
Table 1.4.1: Hospital bed utilization rate in China in 2021. Source: National Health
Commission 2022.
Table 1.4.2: Hospital bed utilization rate in China in 2017. Source: National Health
Commission 2018.
UN LABRADOR.
¡Infeliz de mí!
DICEÓPOLIS.
Por Hércules, ¿quién es este?
EL LABRADOR.
Un hombre desgraciado.
DICEÓPOLIS.
Pues sigue tu camino.
EL LABRADOR.
Queridísimo amigo, ya que las treguas se han pactado solo para ti
cédeme un poco de tu paz, aunque no sea más que por cinco años.
DICEÓPOLIS.
¿Qué te aflige?
EL LABRADOR.
Estoy arruinado; he perdido una pareja de bueyes.
DICEÓPOLIS.
¿Cómo?
EL LABRADOR.
Los beocios me los quitaron en la toma de Fila[216].
DICEÓPOLIS.
¡Oh tres veces mísero! ¿Y aún vas vestido de blanco?
EL LABRADOR.
Ellos, ¡oh poderoso Júpiter!, me mantenían en la más deliciosa
abundancia[217].
DICEÓPOLIS.
¿Qué necesitas ahora?
EL LABRADOR.
Me he estropeado los ojos llorando aquellos bueyes. Si algún
interés te merece Derceles de Fila, frótame pronto los ojos con e
bálsamo de la paz.
DICEÓPOLIS.
Pero, desdichado, yo no soy médico público[218].
EL LABRADOR.
Por piedad, hazlo, para ver si puedo recobrar mis bueyes.
DICEÓPOLIS.
Me es imposible; vete con tus lágrimas a los discípulos de Pítalo[219]
EL LABRADOR.
Ponme siquiera una gota de paz en esta cañita.
DICEÓPOLIS.
Ni el átomo más imperceptible. Vete a llorar donde quieras.
EL LABRADOR.
¡Desdichado de mí! ¡Sin bueyes para la labranza!
CORO.
Este hombre ha conseguido con su tratado muchas ventajas, de las
cuales, al parecer, no quiere hacer partícipe a nadie.
DICEÓPOLIS.
Pon esos callos con miel: asa los calamares.
CORO.
¿Oís cómo levanta la voz?
DICEÓPOLIS.
Asad las anguilas.
CORO.
Nos vas a matar de hambre; y a tus vecinos con el humo y las
voces.
DICEÓPOLIS.
Asad esa con cuidado; que quede doradita.
UN PARANINFO[220].
¡Diceópolis! ¡Diceópolis!
DICEÓPOLIS.
¿Quién llama?
EL PARANINFO.
Un recién casado te envía esta parte de su convite de boda.
DICEÓPOLIS.
Es muy amable, sea quien quiera.
EL PARANINFO.
Te suplica que en cambio de estas viandas, le eches en este vaso
de alabastro una copita de paz, para que pueda eximirse de la milicia y
quedarse en casa disfrutando de los placeres del amor.
DICEÓPOLIS.
Llévate, llévate tus viandas, y nada me des, pues no le cedería una
gota por mil dracmas. — ¿Pero quién es esa mujer?
EL PARANINFO.
Es la madrina de la boda. Quiere hablarte a ti solo, de parte de la
novia.
DICEÓPOLIS.
Vamos, ¿qué tienes que decirme?... — ¡Dioses inmortales! Qué
ridícula es la pretensión de la novia... Me pide que haga de modo que
permanezca en la casa una parte del cuerpo de su esposo[221]. Ea
venga aquí el tratado; a ella sola le daré parte, en consideración a que
siendo mujer no debe sufrir las molestias de la guerra. Tú (A la
madrina.), buena mujer, acerca el frasco... ¿Sabes cómo se ha de
usar? Dile a la desposada que cuando se haga la leva de los
soldados, unte con esto esa parte del cuerpo de su marido que desea
conservar. Llévate el tratado. Traed el cacillo para que llene de vino las
copas.
CORO.
Ahí se acerca uno con el entrecejo fruncido, como si nos fuera a
anunciar alguna desgracia.
MENSAJERO 1.º
¡Oh trabajos y combates! ¡Oh Lámacos![222]
LÁMACO.
¿Quién mueve tanto estrépito en torno de esta casa hermoseada
por ornamentos de bronce?[223].
MENSAJERO 1.º
Los estrategas ordenan que, reuniendo a toda prisa tus batallones y
penachos, partas hoy mismo, a pesar de la nieve, a custodiar la
frontera. Han sabido que los bandidos beocios pensaban invadi
nuestro territorio, en ocasión de estarse celebrando la fiesta de las
copas y las ollas[224].
LÁMACO.
¡Oh estrategas, cuantos más sois peores! ¿No es terrible el no
poder ni siquiera celebrar esta fiesta?
DICEÓPOLIS.
¡Oh ejército bélico-lamacaico![225].
LÁMACO.
¡Oh desgracia! ¿Ya te burlas de mí?
DICEÓPOLIS.
¿Quieres luchar con este Gerión de cuádruple penacho?[226].
LÁMACO.
¡Ay! ¡Ay! ¡Qué noticia tan triste me ha traído este mensajero!
DICEÓPOLIS.
¡Oh! ¡Oh! ¡Qué agradable es la que me trae este otro!
MENSAJERO 2.º
¡Diceópolis!
DICEÓPOLIS.
¿Qué hay?
MENSAJERO 2.º
Corre al festín y lleva una cesta y una copa, pues te invita e
sacerdote de Baco[227]: pero apresúrate: los convidados te esperan. Ya
está todo preparado, los triclinios, los cojines, los tapetes, las coronas
los perfumes y los postres: hay allí cortesanas y galletas, pasteles
tortas de sésamo, rosquillas y hermosas bailarinas, delicias de
Harmodio[228]; pero corre, corre cuanto puedas.
LÁMACO.
¡Infeliz de mí!
DICEÓPOLIS.
¡Infeliz tú, cuando te pavoneas con la gran Gorgona de tu escudo
Cerrad la puerta y preparad la comida.
LÁMACO.
¡Esclavo, esclavo! Tráeme la maleta.
DICEÓPOLIS.
¡Esclavo, esclavo! Tráeme la cesta.
LÁMACO.
Trae sal mezclada con tomillo, y cebollas.
DICEÓPOLIS.
Y a mí peces; me cansan las cebollas.
LÁMACO.
Tráeme aquel rancio guiso envuelto en su hoja de higuera.
DICEÓPOLIS.
Y a mí aquel recién hecho[229]: ya lo coceré yo.
LÁMACO.
Tráeme las plumas de mi casco.
DICEÓPOLIS.
Tráeme pichones y tordos.
LÁMACO.
¡Qué hermosa y qué blanca es esta pluma de avestruz!
DICEÓPOLIS.
¡Qué hermosa y qué dorada está la carne de este pichón!
LÁMACO.
Amigo, deja de burlarte de mi armadura.
DICEÓPOLIS.
Amigo, deja, si puedes, de mirar mis tordos.
LÁMACO.
Dame la caja de mi triple cimera.
DICEÓPOLIS.
Dame ese embutido de carne de liebre.
LÁMACO.
¡Cómo han devorado las polillas mis penachos!
DICEÓPOLIS.
¡Cómo voy a devorar embutidos de liebre antes del banquete!
LÁMACO.
Amigo, ¿no puedes dejar de hablarme?
DICEÓPOLIS.
No te hablo; disputo hace tiempo con mi esclavo. — ¿Quieres
apostar (Lámaco decidirá la cuestión) si son más sabrosos los tordos
que las langostas?
LÁMACO.
Estás muy insolente.
DICEÓPOLIS.
Dice que son más sabrosas las langostas.
LÁMACO.
Esclavo, esclavo, saca la lanza y tráemela.
DICEÓPOLIS.
Esclavo, esclavo, saca aquella morcilla del fuego y tráemela.
LÁMACO.
Ea, sujeta bien la lanza mientras yo tiro de la vaina.
DICEÓPOLIS.
Ten tú también firme y no lo sueltes[230].
LÁMACO.
Saca las abrazaderas de mi escudo.
DICEÓPOLIS.
Saca del horno los panes, abrazaderas de mi estómago.
LÁMACO.
Tráeme el disco del escudo que tiene una Gorgona.
DICEÓPOLIS.
Tráeme el disco de aquel pastel que tiene un queso.
LÁMACO.
¿No es este un burlón sin gracia?
DICEÓPOLIS.
¿No es este un pastel delicioso?
LÁMACO.
Echa aceite en el escudo. Veo en él la imagen de un viejo que será
acusado de cobardía[231].
DICEÓPOLIS.
Echa miel al pastel. Veo en él la imagen de un viejo que hace rabia
al penachudo Lámaco.
LÁMACO.
Esclavo, tráeme la coraza de batalla.
DICEÓPOLIS.
Esclavo, tráeme mi coraza, es decir, mi copa.
LÁMACO.
Con esto defenderé mi pecho contra los enemigos.
DICEÓPOLIS.
Con esto defenderé mi pecho contra los bebedores[232].
LÁMACO.
Sujeta esas correas a mi escudo.
DICEÓPOLIS.
Sujeta los platos a la cesta.
LÁMACO.
Cogeré esta maleta y la llevaré yo mismo.
DICEÓPOLIS.
Yo cogeré este vestido y me marcharé.
LÁMACO.
Toma el escudo y anda. — ¡Oh Júpiter! ¡Está nevando! Tengo que
hacer una campaña de invierno.
DICEÓPOLIS.
Recoge las viandas. Tengo que cenar.
(Salen ambos.)
CORO.
Id alegremente a la guerra. ¡Qué caminos tan diversos seguís
Aquel beberá, coronado de flores; tú harás centinela medio helado
aquel dormirá con una hermosísima joven... Lo digo de veras: ¡ojalá
Júpiter confunda al hijo de Psacas, a Antímaco, poetastro infeliz, que
siendo corega[233] en las fiestas Leneas, me mandó a mi casa sin
cenar! ¡Ojalá le vea yo algún día deseoso de comer un calamar, y
cuando esté ya frito, chirriando en la sartén, servido en la mesa, y
aderezado con sal, en el momento de llevarlo a la boca, un perro se lo
arrebate y escape con él!
Además de ese mal, le deseo otra aventura nocturna. ¡Ojalá a
volver febril a su casa, después de la equitación, se tropiece con
Orestes[234] borracho, y este enfurecido le rompa la cabeza; y que
pensando tirarle una piedra, coja en la oscuridad un excremento
reciente, y al lanzarlo con ímpetu como si fuera un guijarro, yerre e
golpe y le pegue a Cratino![235].
UN CRIADO DE LÁMACO.
¡Esclavos de Lámaco, pronto, pronto, calentad agua en un
pucherillo! Preparad trapos, ungüento, lana virgen y vendas, para
atarle el tobillo. Al saltar una zanja se ha herido con una estaca, se ha
dislocado un pie y se ha roto la cabeza contra una peña; la Gorgona
saltó del escudo, y al ver el héroe su formidable penacho caído entre
las piedras, entonó estos versos terribles:
Por la postrera vez, astro brillante,
Te ven mis ojos; desfallezco y muero.[236]
Dicho esto, cae en una zanja, levántase, se arroja sobre los fugitivos
persigue a los bandoleros, los hostiliza con su lanza. Pero helo aquí
abrid pronto la puerta.
LÁMACO.
¡Ay, ay, ay! ¡Qué agudos dolores! ¡Qué frío! ¡Yo muero, triste de mí
herido por una lanza enemiga! Pero aun será mas terrible mi desgracia
si Diceópolis viéndome en este estado, se burla de mi infortunio.
DICEÓPOLIS (Con dos cortesanas del brazo).
¡Ay! ¡ay! ¡ay! ¡Vuestro turgente seno tiene la dureza del membrillo
Dadme un beso, tesoro mío, un beso dulce y voluptuoso. Pues yo he
sido el que he bebido la primera copa.
LÁMACO.
¡Oh suerte funesta! ¡Oh dolorosísimas heridas!
DICEÓPOLIS.
¡Ah! ¡Ah! Salud, caballero Lámaco.
LÁMACO.
¡Infeliz de mí!
DICEÓPOLIS.
¡Qué desdichado soy!
LÁMACO.
¿Por qué me besas?
DICEÓPOLIS.
¿Por qué me muerdes?
LÁMACO.
¡Infortunado! ¡Qué duro escote he pagado en el combate!
DICEÓPOLIS.
Pues qué, ¿se paga escote en la fiesta de las copas?[237]
LÁMACO.
¡Oh Peán! ¡Peán![238]
DICEÓPOLIS.
Hoy no se celebran las fiestas de Peán.
LÁMACO.
Levantadme, levantadme esta pierna. ¡Ay, amigos míos
sostenedme!
DICEÓPOLIS.
Vosotras, amigas mías, sostenedme también[239].
LÁMACO.
La herida de la cabeza me da vértigos y me turba la vista.
DICEÓPOLIS.
Yo quiero acostarme; no puedo más: necesito descanso[240].
LÁMACO.
Llevadme a casa de Pítalo, cuyas manos son émulas de las de
Peán[241].
DICEÓPOLIS.
Llevadme ante los jueces. ¿Dónde está el rey? Dadme el odre
señalado como premio.
LÁMACO.
Una lanza terrible se ha clavado en mis huesos.
DICEÓPOLIS.
Mirad esta copa vacía. ¡Victoria! ¡Victoria!
CORO.
¡Victoria! Anciano, pues así lo deseas, clamemos ¡victoria!
DICEÓPOLIS.
He llenado mi copa de vino y la he apurado sin respirar.
CORO.
¡Victoria! recoge tu odre, ilustre vencedor.
DICEÓPOLIS.
Seguidme cantando: ¡Victoria! ¡Victoria!
CORO.
Te seguiremos cantando ¡victoria! ¡victoria! a ti y a tu odre.