For this Apollo on Call x W5H Book Club episode, Dave and Luki read Other Rivers: A Chinese Education by Peter Hessler. The book focuses on the quirks and challenges in the education system the author witnessed as a visiting professor in China. At the end, Dave and Luki reflect on an entire year of reading books about China, and how they feel at the end of this journey.

Check out Dave’s Substack for more! 

Web image created by Medhum.

Apollo On Call

It’s well known that in the 1980s and 90s, following China’s implementation of the One-Child Policy, a surplus of orphaned Chinese girls became available for adoption. Many were adopted by well intending American households. What’s less well known is that this surplus of orphans eventually created market conditions for the trafficking of Chinese girls, at least some of whom were forcibly removed from their homes.

Barbara Demick explores the consequences of China’s One-Child Policy, its relationship to the trafficking of Chinese babies, and the overall picture of women’s reproductive rights in modern China in Daughters of the Bamboo Grove. 

Join Luki Danukarjanto and me on this month’s Apollo On Call, as we discuss Barbara Demick’s fascinating look at the process of having babies in China.

Web image by Medhum.org

In 2019, a prominent obstetrician/gynaecologist in Toronto was found guilty of administering intravaginal medications to his obstetrics patients for the purposes of inducing labour without consent. He was subsequently dismissed from his position at the hospital and his career ended. The story was covered in detail in an exposé published in Toronto Life magazine. 

The details of the case are lurid. In the modern age, most obstetricians do group call. Gone are the days when an expectant mother would have both her prenatal care and delivery done by the same physician. Newborn babies are wont to arrive in the world at any given moment, and the traditional obstetrician who drops everything they are doing to attend these deliveries, often in the middle of the night and often with a full day of office work the next day, is all but extinct. Obstetricians now share call duties with a team of physicians. Now, when you sign up with a certain obstetrician, there’s no guarantee that that specific doctor will be the one to deliver your baby, only that someone from their group will be doing the delivery. 

In Ontario, obstetricians are paid more for delivering babies on weekends than they are on weekdays. It’s a nice little reward for doctors who usually work long and unpredictable hours. But in this one hospital, the obstetrics department began to notice that one of their staff had a propensity for babies being delivered predominantly on weekends and evenings and began tracking the matter. 

In time, they discovered that this doctor was inserting tablets of misoprostol into the vaginas of late term pregnant patients in order to induce labour on specific days that were to his advantage, often when the date in question was a weekend. Misoprostol has the ability to induce contractions and is often used in medical abortions. It is not considered to be a medication safe to use in pregnant women to induce labour on command. Needless to say, the patients did not give informed consent for the procedure, nor were they offered the option to decline.The doctor in question was a prominent member of Toronto’s Chinese Canadian community. He had a reputation for being a doctor to the rich and chic. Famous Hong Kong celebrities flew to Canada to have their babies delivered by him and my own patients flocked to him in droves. 

In Toronto, getting a referral to a community obstetrician of choice to deliver your baby is like trying to get your child into an elite private school–no doubt, these actions are often being done by the same parents, just a few years apart. Obstetricians have a set number of expectant mothers they can carry for any given month and once that quota is exceeded, they can’t accept any more patients. In those years when I first started working as a family physician, Chinese immigrant women in my community knew to race to our office as soon as they suspected they were pregnant, so as to get into the front of this doctor’s queue. They were then told by the obstetrician’s office that they were expected to pay a three-hundred-dollar administrative fee in order to guarantee this doctor would be present for the delivery, which they gladly paid.^⁠1 

At the time, it seemed reasonable. Three hundred dollars and your doctor would buck the modern trends of group call and shared team duties and promise to come in on his night off to personally deliver your baby. It all seemed legitimate and altruistic, a call back to a simpler time. If only. 

When the story broke, there was the expected furor in the local medical community. Certainly, the salacious nature of the case, the prominence of the doctor in question, the #MeToo movement which was also taking place around this time, gave the story its pull. 

In the local Chinese community, the story had buzz as well. Toronto, with its large Chinese-speaking population, has several Chinese daily newspapers and the story made headlines in the local Chinese newspapers and filtered its way through all of us. It felt like everyone’s mother had heard of this doctor; he was that well-known. 

As I spoke to patients and friends and colleagues, I discovered so many people around me had had their children delivered by this doctor in the preceding decades. As they reflected on their obstetrics journeys, the stories were all the same. Yes, it was true, many of their babies had happened to arrive on a weekend. Yes, the labour started soon after an assessment, right on schedule and with what had seemed like fortuitous timing at the time. Now, in retrospect, it all seemed fishy and possibly sinister. 

But one thing that I noticed was that this doctor’s actions were met with largely a collective sigh of indifference by the Chinese Canadian community. The lack of outrage most people had towards the story felt odd. Remember, this story was occurring near the height of the #MeToo movement. The idea of a doctor administering intravaginal medications without consent should have, in the West, been seen on the level of battery. At the very least, I expected people to think of it as a violation of a woman’s body. But in the Chinese community, amongst the population that knew this doctor the best, the reaction was muted. Most of his patients that I encountered shrugged off the story. When the subject came up, they were quick to point out to me that he was an outstanding doctor who had helped many people and were disappointed to hear that the doctor was no longer practising. 

In China, women’s reproductive rights is an issue with a thorny history, especially over the last several decades, most of which I was oblivious to until I started working with my own patients. 

The most blatant and obvious reproductive rights issue is China’s One-Child Policy, which ran from 1979 to 2015. During these years, families in China were limited to having only one child, except in special circumstances. The One-Child Policy was formulated in response to the Chinese government’s fear of overpopulation. 

In my naive understanding of China, I was taught the official narrative, that people who had more than one child were subject to higher rates of taxation, and it was the punitive toll of this taxation that kept parents in line. 

But the truth was more complex. What were people’s expectations about birth control? What happened when people didn’t agree with the government’s policy? What happened to people who had an extra child on purpose? What happened if they had a child accidentally?  

When I started working, I soon noticed that all middle-aged women from mainland China had intrauterine contraceptive devices implanted in their uterus. Mostly, they had had these devices placed after delivering a baby years earlier. In many cases, these IUCDs had been present in these patients’ uterus for so long that many of them often forgot to mention it to me, only informing me about the presence of these devices sometimes when they were in their late fifties or early sixties, long after the device had ceased to perform any useful function. Often times, we’d discover that these devices were present during a routine ultrasound, and the patient would remember that yes, they had been wearing an IUCD for so long that they had simply forgotten about it–it had simply become a part of them. This wasn’t an entirely benign situation. The longer an IUCD remained in, the greater the chance it would slowly embed into the tissue of the uterus. Albeit rarely, there are case reports of it rupturing the uterus of women after decades being left in. 

Even after I realized that so many of my patients were wearing IUCDs, I still didn’t fully understand what this meant. I had in my mind envisioned the Western model of women’s reproductive care, that the mother had informed her obstetrician in China at some point after the delivery that she would have an IUCD inserted because yes, she was certain she didn’t want to have another child for a few years. I envisioned a long conversation where a medical professional gave the patient a series of options about contraceptive care. Did the patient want an IUCD? Or maybe to try the birth control pill? Or did the patient want to use natural family planning methods? It was only gradually that it dawned on me, that these were conversations we only had in the West, not conversations women had in China. They weren’t given the option of having an IUCD inserted. They were simply told what to do, or had it done unto them. 

But my women patients didn’t seem bothered by this. They never expressed outrage at having an IUCD. It was again, the collective shrug of indifference. It wasn’t that different than being told that they had to pay taxes. Or have a mandatory retirement age. It was just another curious aspect of life in modern China.  

I couldn’t envision what it meant for a society to exist where a government somewhere could decree that all women would be forced to have a copper intrauterine device placed in their uterus upon having a baby, whether they liked it or not, and that it would remain in place indefinitely. It seemed even more preposterous that almost all the decisions said government made were made by men–the Chinese Communist Party is well known for being almost exclusively male at its highest levels. 

The actual IUCDs that the patients wear bear mentioning also. In North America, IUCD devices like the Copper-T, or Mirena, are little metal or plastic objects that are inserted into the uterus, with a trailing piece of string that dangles out of the uterus. The device itself prevents either ovulation or implantation of the embryo, depending on the IUCD in question. The little piece of string is designed to allow the device to be removed easily in a doctor’s office, where a doctor can tug on the string with a pair of forceps and remove the device. 

In China, the IUCD device is inserted without a string, making it deliberately more difficult for people to remove, even with proper medical equipment. 

As a result, many of my patients, after decades of wearing the IUCD, found that the device could not be easily removed. Canadian-trained gynaecologists, used to the simplicity of tugging on a piece of string and changing the IUCD every four or five years as per the manufacturer’s instructions, couldn’t always remove the Chinese IUCDs. Sometimes, it was because the Canadian-trained gynaecologists didn’t have the practice grabbing IUCD’s without the string. At other times, it was because the device had been put in place so long ago that it had shifted position and could no longer easily be removed. Some of my patients had to go under general anesthesia to have the device removed. Others got on airplanes and flew back to China to get the device removed there by the experts. All of this, I gradually realized, was part of the long-term consequences driven by China’s One-Child Policy. 

For a more detailed discussion of the One-Child Policy, see Barbara Demick’s Daughters of the Bamboo Grove. Demick, an L.A. Times journalist, chronicles her two-decade odyssey to help reunite an American-raised Chinese adoptee named Esther with her birth family in China. Esther was abducted as a two-year-old and then trafficked to an orphanage during China’s international adoption industry heyday in the early 1990s. As it turns out, she has a twin sister, Shuangjie, who stayed with her birth family and the story provides a fascinating case study of the entire issue of women’s reproductive rights and the issue of international adoption. 

In the book, Demick lays out China’s One-Child Policy and its ramifications on the grassroots level, where neighbourhoods were policed by local government family planning offices. These units were akin to local mafioso-like organizations, gangs of thugs who were given carte blanche by the local governments to cajole, threaten, and beat people into towing the party line. And, to top it off, they weren’t above kidnapping the children who violated the government’s restrictions on family planning. 

When it comes to the One-Child Policy, there is a tendency for us as Westerners to discuss it as tomfoolery–a straightforward story of failed macro-economic policy, that the One-Child Policy was short-sighted and hastened China’s likely imminent economic decline. And while this narrative may be accurate, it only scratches the surface. The reality of what happened to people on a personal level is much more complicated. 

As Demick describes it, in the nineties, the One-Child Policy essentially created the market conditions for international adoption and the trafficking of kidnapped children. It isn’t a huge leap of logic to understand that the One-Child Policy begets well-meaning people from the West wanting to adopt babies from China and being willing to pay good money to do so. Once money is involved, human traffickers realize that if they can get good money for babies, then all they need to do is to get more and more babies. Now, cue the kidnappings and forced baby abductions and we get to where we were. It’s a frightening cycle, which only illustrates yet again how economic policy can trickle down to the level of the individual in thousand-fold ways. 

There’s another aspect to Chinese family planning worth pointing out here, which is the desire to have more male children. The Chinese culture is by no means alone in this. Historically, many groups around the world prized boys over girls. In China, the reasons for this have long been established. Traditionally, Chinese culture has long placed an emphasis on families having male heirs. According to Chinese culture, family lineages pass through sons, and daughters are raised but then handed over to other families when they marry, unable to continue lineages of their own. At its most basic level, this meant that your son could look after you in your old age but your daughter couldn’t. 

Growing up as an immigrant in Canada, I accepted that the preference for boys over girls was probably one of those older, primitive world views that Chinese people held in the past, but, like binding women’s feet, surely not something anyone still believed in modern times. After all, I had grown up in a North America where women voted, moms were entering the work force en masse, and dual-income households were becoming more and more the norm. I took it for granted that modern people everywhere would value boys and girls equally. 

And while I had read in books about the gender imbalance in China, about how the One-Child Policy had created a nation with a surplus of boys over girls, I took it as just another example of primitive, traditional Chinese thinking, something from the old world, not something that I would have to deal with directly as a doctor in Canada. 

So imagine my surprise, when in my early years of practice, patients started approaching me, forcing me to confront some of these gender issues head on. 

One patient, an older woman who was already the mother of multiple girls, discovered that she was pregnant again. At the eighteen-to-twenty-week ultrasound, to her disappointment, she discovered that she was having a girl, again. A few weeks later, despondent, she came to my office, asking for a referral for an abortion. She explained to me that she wasn’t primitive or old-fashioned. Indeed, she wasn’t against having girls per say. But she already had so many that it seemed fair that she really didn’t want another one. 

By this point in the pregnancy, she was already precariously close to the twenty-four-week cutoff for late term abortions. In Canada, abortions past twenty-four weeks aren’t allowed. Would it be possible for me to change her estimated date of confinement to so that she could squeeze in just within the 24 week window?^⁠2 I refused to do this, and she ended up returning to the clinic multiple times in the next several weeks, each time suggesting that, telling us in fact, that she had remembered her last menstrual period date wrong. And that if we used her revised calculation, her current pregnancy actually fit in the twenty-four-week window. Needless to say, I did not acquiesce and eventually this patient drifted out of my practice. I never did find out what happened to her and her family of girls. 

Fortunately, not all the stories are so odd. Some patients from China have told me that they were pleasantly surprised to discover that in Canada, at the eighteen-week ultrasound, doctors could reveal the gender of their future children to them if they wished. Finally, they could prepare for the upcoming birth of their child knowing what colour to paint the child’s bedroom and what colour clothes to buy in advance. In China, I was told, this information was kept strictly confidential because the government was afraid that people would go looking for abortions if they found they were pregnant with a girl. 

Of course, now the situation in China is flipped. After decades of the One-Child Policy, China suddenly finds itself facing an economic slowdown, the prospect of an aging population and a more educated working class that wants no part of having more children. More and more young people in China are choosing not to even marry, not to mention start families. 

In a twist of dramatic irony, those same family planning units that harassed women for decades into having less children, have suddenly been tasked with the job of encouraging increased reproductive rates. 

What will the Chinese government do when it’s time to raise its low birth rate? What will it do when it realizes it can’t convince its citizens to get pregnant more readily by offering tax incentives? After all I’ve seen and experienced, it’s something I don’t even want to think about but could be just around the corner. 

I’ve long struggled to understand this concept of just how powerful the Chinese government is and how much impact it is able to have on its citizenry. Because my grandparents fled China after the Civil War in 1949 and my parents grew up in Taiwan under martial law, I’ve always had a bird’s-eye view of how Chinese politics can affect the lives of everyday people. I have an aunt who I’ve never met because she didn’t make it out of China in 1949 and became separated from our family–she wouldn’t see my father, her brother, for almost forty years. In recent years, I’ve read countless books about government reforms in China. I saw how China handled Covid-19 in the news. I’ve visited China and seen the gleaming new buildings and multi-lane superhighways humming with electric vehicles. But none of it has spoken to me as loudly as this collective shrug of indifference that I’ve encountered from my patients when it comes to women’s reproductive rights. 

Sometimes, I wonder what the psychic toll of a person doing something they don’t really want to do might be. What if they’re forced to get a tattoo that they don’t want? Or forced to cut their hair in a certain way? 

What if they’re forced into a marriage they don’t want? Or forced to have a baby they don’t want? Or forced to give the baby away against their will? 

They don’t even have the option of agreeing to any of these things. What if these actions are just done to them whether they like it or not? 

But then what about this: what is the psychic toll if they’re to wear an IUCD for the next thirty years, whether they would like to or not? 

What’s the toll if they’re given intravaginal misoprostol so that their baby can be born on an auspicious day? 

What’s the toll if they’re given intravaginal misoprostol so that an obstetrician can deliver the baby on a day convenient for him? 

If all of these decisions are simply made for a person by an aggressive husband, we’d call it abuse and everyone would be screaming bloody murder. But if these decisions are decreed by an even higher authority, an all-powerful political party or an all-seeing authoritarian government, then what? Would everyone just accept it as just another cultural fact of life, like using chopsticks instead of a fork? It seems like they would. 

To hear further discussion about Barbara Demick’s Daughters of the Bamboo Grove, have a listen to my discussion about it on Apollo On Call, the podcast of medhum.org. 

1. In Canada, health care is publicly funded but doctors can charge fees for services not covered by the public health care system. This can take the form of administrative fees as well as fees for certain medical and surgical procedures that the government health insurance doesn’t cover. 
2. The estimated date of confinement is the projected due date for a pregnant mother. It can be calculated as 40 weeks from the date of the pregnant woman’s last menstrual period, or estimated using prenatal ultrasounds. 

Web Image by Medhum.org and Fred Moon 

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 686

From Tigers to Otaku

09.16.25 1539

The Happiest Couple

07.28.25 1291

The Things We Don’t Talk About When We Talk About Dying 

05.13.25 1871

Mrs. Lin is a fifty-five-year-old woman who has lived alone in Canada for many years while her husband lives back in China. Her two sons are both working and out of the house. Last week, she discovered a new breast lump while showering. A few days later, she’s in my clinic to get the lump checked. As her family doctor, I order a mammogram and an ultrasound. When the results of these tests come back a few days later, the report indicates that the findings are suspicious for malignancy and a biopsy is necessary. 

Mrs. Lin returns to the clinic and I relay the information to her. I try not to mention the word “cancer” to her, but it hangs between us, powerful even if it remains unsaid. I urge her not to jump to worst case scenarios, but we both know that one way or the other, this is life altering news. I promise to order a referral to the breast diagnostic clinic at the community hospital nearby and that the breast centre will reach out to her in the next week or two. 

Later in the week, I receive a fax from the breast clinic. They’ve been trying to reach my patient by phone but with no success. Do we have another way of contacting her? 

I instruct my office staff to try to reach the patient. They call repeatedly for a few days. The breast clinic appointment is scuttled but I’m not actually worried. I’ve seen this pattern many times before. I am certain the patient has already flown the coop. 

A few days later, my hunch is proven right. My nurse manages to reach one of Mrs. Lin’s sons. His mother is safely back in China, seeking medical attention there. They’ll call us when she returns sometime next year. 

When my father boarded a plane in Taiwan in 1967 to come to Canada on a one-way ticket for graduate school, my grandmother saw him off at the airport. She gave him $1000 and said, “I’ll see you in about ten years.” 

She wasn’t far off. In fact, he didn’t return to Taiwan until 1974, for his wedding. 

That was what being a Chinese-Canadian immigrant was like back in those days. A journey to the other side of the world was truly a journey into an unknown abyss. Letters marked “airmail” with the blue and red checkered envelope edges took weeks to circumnavigate the globe. If my father wanted to call his parents, he’d reserve the call for special occasions like Chinese New Year because long distance rates were exorbitant. And even then, he’d be careful to limit the call to one minute and fifty seconds because exceeding the two-minute mark meant paying unnecessary fees. 

Immigrating was essentially a one-way trip. Immigrants like my father rarely considered the prospect of flying back home because it was something most of them simply couldn’t afford. There were only two acceptable occasions to fly home: your own wedding or a death in the family. 

The journey for today’s Chinese-Canadian immigrants is different. Not only can they communicate easily with those back home using apps like WhatsApp, WeChat and Line on an hourly basis, but based on my observation of my Chinese Canadian immigrant patients, even those who struggle financially, seem to have a reserve fund that they can dip into and use to return to China on a moment’s notice. Home is never more than a one-day airplane flight away. 

And people fly back for all manner of reasons now: family illnesses, Chinese New Year, summer vacations, and most definitely, for expediting medical investigations. 

The fluidity with which patients move back and forth speaks to a difference in what motivates immigrants to come to Canada. When my parents’ generation left China or Taiwan or Hong Kong, often it was to trade a future bleak of possibilities for a possibly prosperous future. But for many of today’s Chinese immigrants, it’s a trade of one hopeful future, for possibly, a slightly better one, but with the option to go back if this future in the West doesn’t work out. 

Health care has become part of this back-and-forth fluidity. It used to be that the health care trade off would have been clear–Canadian health care was more advanced than that in China in the sixties and seventies. But that’s not entirely true anymore, and today’s immigrants arrive with a great deal more reticence about our health care system. 

Health care always presents unique challenges to an immigrant population. Illnesses imply a degree of immediacy and urgency. They play out on their own timetables – they don’t wait for people to become comfortable with the language or culture of a place before occurring. 

So the new immigrant is forced to face the health challenges of regular life—acute illnesses, chronic diseases, bodily injuries, babies being born, and even the occasional life-threatening-situation without the social support structure that they would have had back home. All this is part of the bargain that the new immigrant strikes with their adopted country. And so they pray that nothing major will befall them, but when something invariably does, what do they do? 

In the previous generations, immigrants here had little recourse but to seek out solutions in the Canadian health care system. Whether their English was up to snuff or not, they were forced to navigate the system here. Many Chinese immigrants like my parents flocked to Chinese-speaking doctors like me in the hope that at least less would be lost in translation if they found a Chinese person holding the stethoscope. 

The modern immigrant though, has the luxury of straddling the line between the Canadian and Chinese health care systems, keeping one foot in China’s health care system and another foot in Canada’s. 

Unhappy with the wait times for elective knee surgery in Ontario? No problem. A doctor in Taiwan or Hong Kong will have you on the table in the OR in a few weeks, not months. 

New discovery of lymphoma? No need to wait for your family doctor to refer you to an oncology clinic and for that clinic to send you for imaging before finally making a decision on treatment—a process that can easily span into months. If you fly back to China, you can walk into a specialty clinic the next day, see a doctor by lunch time and have imaging and an oncology plan done by the end of the week. 

When it comes to China, the western world has a tendency to see things in stark black and white terms: e.g., freedom is good and communism is bad. As a Chinese Canadian physician, I find that this type of thinking carries over to our view of the health care system. Medical students in Canada, are taught that the Canadian health care system is a virtuous, humane social experiment, one of the country’s proudest achievements. It’s drummed into us that it delivers world-class care to the majority of its people. And we’re proud to be trained in it. Sure, it has its problems, but nothing’s perfect. 

There is a hidden side to this curriculum though. If we’re world class here, what about health care systems in other places? What about Africa? What about South America? What about China? 

Perhaps unintentionally, we’re taught to look down on the systems of other countries. We use words like ”developing“ and “evolving” to describe health care systems in these places. But in private, we often shake our heads in exasperation and use far worse language than that. 

These stereotypes were only reinforced when I started practicing medicine about fifteen years ago. The requests of my Chinese patients, often rooted in their own experiences with the health care systems they had left behind, drove me batty on a daily basis. 

I’d try to explain to my patients that, “Yes, that might be the case there. But you don’t really need any of those things.” But it’s hard to convince someone that everything they’ve accepted as truth may not be correct. 

The worse complaint was always about the wait times. This was one that I could not refute. It’s well-known that wait times for medical procedures in Canada are criminally lengthy. But whereas my Canadian patients had nowhere else to go and would just vent to me about the breaking down of our country’s beloved health care system, or try to drive a few hours to Buffalo to get an MRI, my Chinese patients had the luxury of options. They could hop on a plane, land in China or Hong Kong or Taiwan by the end of the week and get whatever they wanted within days, not weeks or months. 

I should point out that the feedback from patients about the Canadian health care system wasn’t always negative when compared to back home. I learned that the fifteen to twenty minutes I allocated to speak to each patient was approximately twelve to eighteen minutes more than they got in the typical Chinese hospital. 

Still, there were many frustrations that I was unprepared for. Patients would return to my clinic armed with reams of paperwork (all in Chinese), documenting checkups and physical exams that they had done overseas: lab tests and CT scans that had no indication for being ordered, medications that they had been prescribed that were not really indicated. 

If modern medicine in the West suffers from an over-reliance on medical imaging and pharmaceuticals at the expense of a more prudent and holistic approach to care, then modern Chinese medicine has become Western medicine’s adopted twin, with all the same problems we have, except with even less sense of restraint and caution. 

Mr. Zhang is a middle aged, Chinese man with diabetes. In China, people routinely retire in their early fifties and one of the perks of retirement is long term health insurance, so even though Mr. Zhang has lived in Canada for almost fifteen years, he still can access Chinese health care whenever he is back home. 

Mr. Zhang isn’t alone in returning home to seek health care. Even those without health insurance often choose to pay out of pocket to access health care in China on a regular basis because the costs aren’t prohibitive 

Because Mr. Zhang travels back and forth between China and Canada on a regular basis (after all winters in Canada are cold), he needs doctors on both sides of the world to help him manage his long-term diabetes. What he’s discovered is that the quality of care in both countries is, for him at least, comparable. The general procedures for diabetes, routine blood testing, and medication adjustments, are similar in both places. But there are some noticeable differences. 

He informs me that in China, the health care system is heavily incentivized by the profit motive. Hospitals make more money if they achieve certain revenue quotas, and this is passed on to the doctors, who in turn pass this mindset down to the patients. 

At the same time, it’s well known to him and all his friends, that in Canada, with a public health care system, cost-cutting is much more of an issue. 

The doctor as gatekeepers of the health care system is sometimes a difficult concept for patients to understand. Doctors in China are not really gatekeepers of the system the way they are in Canada, where doctors spend a great deal of time being instructed on not over-ordering tests. Not all medical investigations are necessary. Extra tests beget extra costs and may engender unnecessary anxiety and have deleterious consequences for the patient-just think about the patient who worries about a lung nodule that will never cause them problems once it’s been spotted on an unnecessary chest X-ray. These are hard lessons that even medical practitioners in the West struggle with at times. For my patients from China, this concept is irrelevant. In a privatized system where patients can pay for what they want, getting an unnecessary MRI is no different than spending money on a fancier car or an extra helping of dessert: nobody really needs it, but if they can afford it, then why not? 

So if I try to explain to my patients why I don’t think they need that MRI they really want, they think I am just trying to save the government of Canada money. If I am really hard-nosed about it, they just might turn around, get on a plane and have the test done in Shanghai or Taipei by the end of the week. 

In China, if I want an MRI and can afford to pay for one, then who is anyone to stop me from getting what I want? If a cardiologist makes more money for pushing a certain type of stent at a patient, who is going to stop them from recommending it to patients who might do just as well with a less aggressive intervention? 

To be sure, these are problems that exist in many parts of the world, even here. But reviewing the stacks of lab results and CT scans that my patients lug back to Canada from overseas, I can’t help but feel that my patients have stumbled upon the Wild, Wild, West of health care-except it’s in the Far East. 

There is of course a downside when patients straddle two countries for their healthcare. Countless times, I’ve had patients return from overseas after having had a major health calamity. Maybe they had breast cancer diagnosed in China, or a screw placed in their hip after a fall, but now that they’ve returned to Canada, no specialist office will see them.  

Dutifully, the patient brings copies of their hospital notes from China, copies of their CT scans and MRIs, but nobody here is willing to read them because nobody here trusts what the report says. If the documents are written in Chinese, Canadian doctors usually can’t read it. Even if they could and wanted to trust it, can they really do so medico-legally? And so it’s the patient that gets left in the lurch.  

In the end, armed with a Chinese-Canadian dictionary in my early years in practise, or more recently Google translate, I’ve learned to muddle through. With my admin staff translating the documents for me, I can usually piece together what procedure a patient has had done overseas. Then we try to match them with the appropriate follow up here, often repeating the testing and imaging so that patients can access care here. 

But it’s getting better. In my early years, I couldn’t find any oncology clinics willing to follow my patients who had started their chemotherapy overseas. Many of these patients flew all the way here to use their hard-won Ontario health care card, only to have to fly back home shortly thereafter when they realized they weren’t going to receive timely care in Canada. These days, I’ve seen more care handoffs take place here smoothly. Truly, the health care world is becoming a little friendlier to immigrants. 

It used to drive me crazy when my patients sought out health care overseas. In medical school, we’re taught a very idealized version of medical care, something akin to the traditional country doctor’s life straight out of the 19th century. A patient feels unwell. They seek out a local physician. The physician solves the problem or directs them to someone else who can. The problem is solved, and life goes on. 

But in real life, I saw that patients didn’t always stay in one place. Sometimes they asked me for help first. Then they’d go overseas. At other times, they came back from Asia and needed my help deciphering what had happened to them there. And back and forth they went. 

Sometimes I’d get exasperated that they were receiving substandard care overseas. At other times, I’d gain an appreciation that they really could get better, faster treatment for certain things in China that in Canada would have taken ages. In time, I developed a grudging respect for health care in China. 

As I worked with patients who were navigating these two systems simultaneously, I felt myself drawn into a curious, political dilemma. Which health care system is better? 

Sometimes patients would pull me aside and ask me what they should do, fly back to China and seek urgent care or wait a bit longer to see their specialist here in Canada? 

The issues were always some variation of the same theme, a weighing of trade-offs: comfort with the language, wait times, medical expertise, as well as the family support system, all bundled into one massive equation that boiled down to a simple binary question: China or Canada? 

I’ve found my own stance on the issue change over time. When I first graduated from medical school, armed with all my pro-Western biases, the answer was almost certainly Canada. 

But in recent years, I’ve watched medicine advance in China from afar, through what my patients tell me, and through the medical records and histories that they bring back to me. Perhaps there’s still a lot of overkill in investigations on the other side of the ocean, but often the quality of medicine isn’t that different from what it is here. And it’s almost certainly faster. And if you can pay for quicker care, why not? Moreover, many of these Chinese immigrants have family support networks back home that simply don’t exist here. For them to return home for their care simply makes rational sense. Nothing reminds someone of how foreign they are as being in a cold, sterile hospital environment where nobody speaks your language. 

More than a year after she departed, Mrs. Lin returns to my clinic. Following a lumpectomy and ten rounds of chemotherapy, the doctors in China have instructed her to remain on estrogen receptor therapy for the next five years. 

Why did she return to China for medical care? Despite living in Canada for more than a decade and having a passable command of the English language, she still felt that for something as serious as this, she wanted to be someplace she could speak her native tongue. Plus, she would have family members there to support her. Left unsaid is that the entire medical procedure in China took days to arrange not weeks as it would have here. 

I refer her to a medical oncologist, who reports back to me that she is overall, in agreement with the patient’s treatment plan. She replaces the patient’s estrogen treatment with an alternative agent that is available in Canada. 

Web photo by Zac Ong 

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 686

From Tigers to Otaku

09.16.25 1539

The Happiest Couple

07.28.25 1291

The Things We Don’t Talk About When We Talk About Dying 

05.13.25 1871

One Patient, Two Systems 

02.24.25 2532