Rehabilitation, Disability, and O&P Care in China: A Firsthand Account

I recently had the honor of participating in a United States delegation to China, part of an annual dialogue called the U.S.-China Coordination Meeting on Disability in which the two countries have been engaged for the past four years. Disability is one of the few human rights topics the Chinese are willing to meaningfully discuss with our country of late. The delegation was orchestrated by the State Department's Bureau of Democracy, Human Rights, and Labor, and our official host was the China Disabled Persons' Federation (CDPF). It was a fascinating trip with a full day of formal dialogue, as well as site visits, ceremonial meals, and discussions with Chinese disability advocates. CDPF is known in China as a government-organized non-governmental organization (GONGO), but essentially, we were meeting with the Chinese government. The three topics identified for this fourth delegation were rehabilitation, employment of people with disabilities, and adaptive sports. As one of a seven-member delegation, I was invited to represent rehabilitation. Other delegates included a senior executive responsible for disability inclusion at Walmart, a disability employment specialist from the Department of Labor, and several State Department officials responsible for the international disability agenda. The delegation's official business began as soon as we landed in Beijing after the 14-hour flight. We were brought to the U.S. Embassy where we met in the residence of a former senior diplomat. With interpreters, we met with several Chinese disability advocates, including representatives from Handicapped International, which has recently been renamed Humanity and Inclusion (HI). It was a fascinating dialogue that underscored the differences in disability advocacy in the two countries. Audacious Goals

China is pursuing its 13th five-year plan, which began in the 1950s. These plans are grandiose in scope. For instance, under the current five-year plan, China is focusing on improvement of people's welfare. China intends to eliminate poverty by the year 2020. Its goal, stated many times throughout the trip, is to have everyone in China attain "moderate prosperity" by having housing, employment, and medical care. They intend to "remodel" the countryside, accelerate the assistive device industry, and create national standards for special education, among other major objectives. Employment is viewed as a key goal to attain moderate prosperity. While most of the cities in China are composed of working age adults living in one apartment building after another, seniors, children, and most people with disabilities tend to live in the rural areas, according to HI. There is a concerted effort to relocate millions of rural Chinese to the cities where they can be industrious and obtain employment. In fact, one of the cities we visited, Xi'an, a provincial capital city that served as the capital of China during 15 different dynasties, is scheduled to grow from a current population of nine million (the size of New York City) to 15 million people within three years. To its credit, China has adopted the United Nations' Convention on the Rights of People with Disabilities (CRPD)—the U.S. has not ratified the CRPD—and appears to be pursuing many policies to come into compliance with that treaty. Article 26 of the CRPD addresses the need for member countries to have the capacity to provide comprehensive rehabilitation and habilitation services to the population. China also participated in the development of the World Health Organization's Rehabilitation 2030: A Call for Action, which establishes a series of goals and benchmarks on rehabilitation access in member countries. Because of these initiatives, as well as China's overall interest in showcasing its disability policies as a manifestation of their human rights record, the Chinese government appears eager to make major strides in rehabilitation and disability policy. Therefore, collaboration with the U.S. rehabilitation and disability communities appears to be a current priority for them. Dialogue on Rehabilitation and Prosthetics/Orthotics

The formal day of dialogue started with the president of the CDPF and U.S. Ambassador Terry Branstad offering opening remarks. The rehabilitation discussion followed as the first topic of the day, and I presented an overview of rehabilitation in the United States. Highlighting my experience over rhetoric, I peppered my presentation with my own rehabilitation story after bilateral limb loss when I was ten years old. The fact that I had extensive access to rehabilitation services and prosthetic limbs, remained in a public school (not a segregated one), participated in sports, and eventually became employed as an attorney were all instructive to the main points of the dialogue. I noted that 11 rehabilitation hospitals in China are currently accredited by the Commission on Accreditation of Rehabilitation Facilities International (CARF), and that standards such as these are critical to ensuring consistency, quality, sustainability, and a focus on the person served. China's presentation was impressive in scope and very focused on numbers. The director of rehabilitation for the CDPF described the progress China had made under the five-year plan issued in 2017, which identifies rehabilitation as a primary goal. China asserts that 6 percent of its population has disabilities, approximately 85 million people (there are approximately 55 million people with disabilities in the United States, which has one third the population of China). Officials in China appear to measure healthcare in terms of the capacity to deliver services rather than in outcomes and results. For instance, China reported it has 450 rehabilitation hospitals, 3,000 rehabilitation units of acute care hospitals, and 75 universities that have rehabilitation as a major. There was no statistic cited for the number of O&P clinics either affiliated with hospitals or free-standing facilities. One of the apparent shortcomings of the Chinese healthcare system is lack of trained rehabilitation professionals, including O&P practitioners. In fact, China is breaking ground on a national rehabilitation university in southern China that they expect will produce well-trained rehabilitation professionals, including orthotists and prosthetists, to serve the population. The CDPF director of rehabilitation was candid in assessing China's continuing challenges in rehabilitation. He admitted that China lags behind in sufficient personnel and facility rehabilitation capacity. China provides some rehabilitation following illness or injury but not comprehensive rehabilitation. The sophistication of rehabilitation professionals is fairly low and undifferentiated. There are still high levels of disability in certain areas of the country, particularly rural areas. Stigma and discrimination continue to be a problem, and many older Chinese people have chronic conditions. China's goal is to ensure access to rehabilitation for everyone. To accomplish this, there are five immediate goals, including: • Include rehabilitation in the mainstream healthcare system. • Improve policies that guarantee access to rehabilitation when needed. • Increase government subsidies for assistive devices and technologies. • Focus on children and provide greater public support. • Mobilize existing rehabilitation capacity and expand private sector investment.

The CDPF rehabilitation director concluded his remarks with an aspirational statement that China seeks to provide everyday access to rehabilitation. He requested ongoing dialogue and collaboration between the two countries. His remarks were followed by presentations from representatives of rehabilitation programs in China including a spinal cord injury program that appeared similar to what we would refer to as an independent living center. The day of dialogue continued with an in-depth presentation and discussion of employment and sports and recreation for people with disabilities. Visiting a Rehabilitation Hospital and O&P Clinic in Xi'an

The next morning, the U.S. delegation flew to Xi'an, an ancient city in Shaanxi Province in central China. We toured Shaanxi Rehabilitation Hospital, an aging building in a dense part of the city with multiple floors devoted to various rehabilitation services and patient populations. The tour itself was chaotic given the number of patients and family members in the therapy rooms, the entourage accompanying the tour, the many cameras following our delegation, and the language barrier. I noticed a dearth of therapy equipment that would be considered standard in the U.S. Where therapeutic assistive devices and other technology were present, they were not always being used. I was not aware of any physician presence and the therapists were not differentiated in any noticeable way. The physical layout of the building provided limited room for therapy services to be delivered to the large patient population, including the pediatric floors. Another portion of the building housed a prosthetic/orthotic clinic, which I had asked to tour prior to the trip. There was one room where various prosthetic and orthotic devices and components were displayed on back-lit glass shelves. Some of the household name brands were included, but no microprocessors or other advanced technology were displayed. The gait training area and the fitting room offered a better gauge of the level of quality and sophistication of the O&P capabilities. Of the two patients I met as they walked in parallel bars, the prostheses did not appear to fit well, their gait was not optimal, and the prosthetic technology was very basic. A simple strap was being used for suspension rather than more advanced suspension techniques. The clinic had arranged for a fitting demonstration of a lower-limb orthosis and a prosthesis. As the practitioner removed a plaster cast from each patient, I noticed the lack of digital scanning technology and other more contemporary fitting equipment or techniques. The hallway featured a display of wheelchairs and basic complex rehabilitative technology mobility devices, but I did not see a seating and positioning clinic or a mobility device or O&P laboratory. Potential Future Collaboration

With my knowledge of multiple past and present interactions between U.S. rehabilitation/O&P and rehabilitation service providers in China, there is a question as to meaningful next steps. The Chinese are clearly focused on improving their rehabilitation system in the near term and are interested in collaborating with the United States provider community as they pursue this priority. The involvement of the U.S. State Department as well as the CDPF suggests a more formal, government-involved collaboration than perhaps previous exchanges between the U.S. rehabilitation/O&P provider communities and China on this topic. The most immediate opportunity for collaboration is China's creation of a national rehabilitation university, which, while under way, still appears to be in early stages of development. The inroads in China made by the rehabilitation and O&P fields over the past decades may be ripe for expansion in this environment and new associations and collaborations appear to be very possible. Peter W. Thomas, JD, is a principal in the Powers Pyles Sutter & Verville Legislative Practice Group, Washington, and general counsel for the National Association for the Advancement of Orthotics and Prosthetics (NAAOP).

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