HEALTH CARE IN CHINA
China Japan Friendship HospitalChina has the most hospitals (25,400) and the most doctors (4.1 million) of any country in the world. In 1949 when the Communists came to power there were only 2,600 hospitals in China. In the early 2000s there were 62,000 hospitals and clinics with a total 2.6 million beds, or 2.33 per 1,000 people. [Source: Statista, Library of Congress]
Physicians density: 2.23 physicians/1,000 population (2019)
Hospital bed density: 4.3 beds/1,000 population (2017) [Source: CIA World Factbook, 2022]
China had nearly 1.7 physicians per 1,000 persons and about 2.4 beds per 1,000 persons in 2000. As of 2004, there were an estimated 164 physicians, 104 nurses, 29 pharmacists, and 4 midwives per 100,000 people.[Source: Worldmark Encyclopedia of Nations, Thomson Gale, 2007]
According to the Financial Times: Beijing has increased state spending on healthcare from about 2 percent of gross domestic product to nearly 3 percent over the past decade as it rolled-out a basic system of state-backed medical insurance covering 95 percent of the population. China has achieved “some of the most pronounced gains” in healthcare access and quality improvement worldwide from 2000 to 2016,according to research published in The Lancet in 2018. But it added that the country’s regional disparities were among the widest. [Source: Tom Hancock and Wang Xueqiao, Financial Times, December 31 2019]
National health services in China provide both Western and traditional Chinese medicine. They are under the supervision of the Ministry of Health, which as traditionally emphasized preventive medicine and general improvement of sanitary conditions. Western medical facilities are much more accessible in the cities than in the countryside. Even those who have access to Western medicine often use a combination of Western and traditional Chinese medicine but the government prioritizes Western medical practices. [Source: Eleanor Stanford, Countries and Their Cultures, Gale Group Inc., 2001; Junior Worldmark Encyclopedia of the Nations, Thomson Gale, 2007]
Approximately 90 percent of the inhabitants of China had access to health care services in the mid 2000s. Health care in China can range from a tooth pulled by sidewalk dentist at a local market to a sophisticated transplant operation performed at a major city hospital. A rural birth costs around $35. One of the busier departments in Chinese hospitals and clinics is the abortion clinic.
China’s laws formally ban foreigners entering the country with “serious psychiatric illness, infectious pulmonary tuberculosis and other infectious diseases that may constitute a major threat to public health.” It used to ban all foreigners with “psychiatric illness, leprosy, AIDS, sexually-transmitted diseases, active pulmonary tuberculosis and other infectious diseases.” In April 2010, China lifted the ban on people with HIV/AIDS and leprosy entering the country.
Health Care Expenditures in China
Current Health Expenditure: 5.4 percent of gross domestic product (GDP) (2019). Current Health Expenditure (CHE) describes the share of spending on health in each country relative to the size of its economy. It includes expenditures corresponding to the final consumption of health care goods and services and excludes investment, exports, and intermediate consumption. [Source: CIA World Factbook, 2021]
In the 2000s, about 4.5 percent of GDP was allocated to healthcare, half of which came from the private sector. By comparison the average healthcare expenditure of countries in the European Union at that time was 9 percent of GDP, while in the United States it was nearer to 16 percent. In the 1990s, the government fixed prices on all medical services and paid doctors like public officials. The salaries and fees were often very low. This led those in the medical profession to seek other ways to make money and to doctors choosing better paid professions.
China's healthcare spending was estimated to be around $1.3 trillion in 2020, up from $357 billion in 2011, according to McKinsey & Company consultancy. This is a lot of money for the Chinese government to deal with alone. The market for drugs and services has attracted the likes of e-commerce giant Alibaba Group Holding and hospital operator Phoenix Healthcare. [Source: Adam Jourdan, Reuters, April 12, 2016]
According to The Times health care costs in China rose 382 percent between 2007 and 2012. China has increased spending on health care reform with overall expenditure in 2012 at 719.9 billion yuan, a 12 percent increase from the previous year. But this has not been enough to keep pace with the rising costs.
Health expenditures on a purchasing parity power (PPP) basis were US$224 per capita in 2001, or 5.5 percent of gross domestic product (GDP). Some 37.2 percent of public expenditures were devoted to health care in China in 2001. However, about 80 percent of the health and medical care services are concentrated in cities, and timely medical care is not available to more than 100 million people in rural areas. To offset this imbalance, in 2005 China set out a five-year plan to invest 20 billion renminbi (RMB; US$2.4 billion) to rebuild the rural medical service system composed of village clinics and township- and county-level hospitals. [Source: Library of Congress, August 2006]
Treatment of the Sick in 19th Century China
In 1899, Arthur Henderson Smith wrote in “Village Life in China”:Perhaps there is no single particular in which the Orient and the Occident differ more widely than in the utter disregard of Orientals for what we understand by privacy and for quiet. The lack of the latter is indeed often vaguely felt, but as it is a blessing known only by the imaginative faculty and never from experience, its absence has none of the intolerable features which we should associate with it. The moment that any Chinese is ill, the first step is to send in every direction to notify all sorts and grades of relatives, many of whom will feel it their stern duty to drop whatever they are doing, no matter what its importance, to go, and “take a look.” This inspection not infrequently extends for days and sometimes for weeks, when the presence of the relative has not the smallest relation to the care of the sick person, except as a hinderance by adding to the throng that hover over the patient, each with his endless questions as to how he feels now, and each with fertile suggestions as to articles of food vying with one another in preposterousness. Few of us would not welcome death as a relief from the experiences incident to serious illness under Chinese conditions, but under these conditions all Chinese are born, live, and die. [Source: “Village Life in China” by Arthur Henderson Smith, Fleming H. Revell Company, 1899, The Project Gutenberg; Smith (1845 -1932) was an American missionary who spent 54 years in China. In the 1920s, “Chinese Characteristics” was still the most widely read book on China among foreign residents there. He spent much of his time in Pangzhuang,a village in Shandong.]
“If a sick person is considered to be beyond the possibility of recovery, the next step is to “put on the clothes,” that is, those in which he is to be buried, a process which involves pulling him about to an extent which it is distressing to contemplate. In the case of old men there are sometimes angry disputes about the property in the immediate presence of death, and in that of wives — especially younger ones — if there is any considerable property, it will not be strange if the house is visited by relays of go-betweens intent upon proposing an eligible successor to the one about to depart, so as to be certain to forestall other offers. These negotiations may take place in the immediate presence of the dying woman, perhaps two or more strangers striving at the same time to get a hearing with their rival proposals!
“The writer is acquainted with a family in which this took place, and one of the offers was accepted, but the sick woman contrived not to die after all! The agreement, however, was valid, and the prospectively stricken husband thus found himself provided with two lawful wives, each of whom subsequently bore him sons. Strange to say the family life is in this instance a comparatively peaceful one. Should a wife die, it is often a short time before the marriage of the next one takes place, an interval regulated not by sentiment, but by the difficulty of raising funds. Soon after the wedding may come the funeral of the predecessor.
Evolution of Health Care in Communist China
Siu-wee Lee wrote in the New York Times: China once had a broad, if somewhat basic, primary health care system. “Barefoot doctors” roamed the countryside treating minor ailments. In the cities, people got their health care at clinics run by state-owned companies.[Source: Siu-wee Lee, New York Times, September 30, 2018]
“China’s “barefoot doctor” system was one of the Communist revolution’s most notable successes. In 1965, Chairman Mao, troubled by the lack of health care in the countryside, envisioned an army of people who spent half their time farming (many worked in the fields without shoes) and half their time treating patients. They weren’t doctors, but rather a sort of health care SWAT team. The authorities gave them a short training period — several months to a year — and a bag of limited medicine and equipment.
“Average life expectancy in China increased to 63 years in 1970 from 44 in 1960, according to Theodore H. Tulchinsky and Elena A. Varavikova, authors of “The New Public Health,” a book about global medical care. The maternal mortality rate in rural China fell to 41.3 per 100,000 people from 150 per 100,000 before 1949, according to a 2008 article published by the World Health Organization. In the same period, the infant mortality rate fell to 18.6 per 1,000 from 200.
“But the public was fed up that it could not get medical treatment whenever or wherever it wanted. People needed a referral to see a specialist in a hospital. In the mid-1980s, the government lifted the barriers, allowing people to be treated in hospitals. At the same time, China began an economic overhaul that led to the dismantling of the entire system. Government subsidies were cut drastically, and hospitals had to come up with ways to generate profits.
Health Care in the Mao Era China
Improved health care was considered one of the great success’s of the Mao era. Barefoot doctors brought modern medicine and prevention strategies to places that had minimal health care. These and other Chinese health care workers are credited with 1) reducing infant mortality to a lower level than in New York City, 2) eradicating small pox and nearly eradicating sexually transmitted diseases, tuberculosis and schistosomiasis and 3) raising the average life span of Chinese from 35 in 1949 to 68 years in 1979. Many of China's health statistics are comparable with those of a much richer country.
The 1950s was characterized by mass campaigns to deal with major public health problems. According to the Worldmark Encyclopedia of Nations: These included nationwide cleanup campaigns and mass educational programs in the sanitary preparation of food, the treatment of drinking water, personal hygiene, and waste disposal. The entire population was mobilized to eradicate the four pests—rats, sparrows, flies, and mosquitoes—with mixed results. Epidemic prevention centers were established to carry out massive immunizations, while parasitic diseases, affecting hundreds of millions in China, were also attacked. As a result, schistosomiasis, malaria, kalaazar, and hookworm are thought to have been largely brought under control. [Source: Worldmark Encyclopedia of Nations, Thomson Gale, 2007]
“During the Cultural Revolution in an effort to even out the disparity between rural and urban health services, medical personnel from hospitals (as much as 30–50 percent of a hospital's medical staff) were sent to the countryside and the number of locally trained paramedical personnel, called barefoot doctors, expanded. These paramedical personnel—young peasants or middle school graduates—were trained on the job by township doctors or in two-month courses at township health clinics. "Barefoot doctors" and brigade health stations were still the major deliverers of health care in the countryside.
Since 1978 health care improvements had slowed. Life expectancy has only increased by 3.5 years and deadly diseases such as tuberculosis and schistosomiasis have returned. China spends only 4 percent of its gross national product on medical care, compared with 15 percent in the United States. Some criticize the Chinese government for spending billions on huge infrastructure projects like the Three Gorges Dam rather than providing cheap, basic health care.
Health Care in China in the 1980s
In the mid-1980s, the Chinese government lifted the barriers that had previously kept people from being treated at hospitals. At the same time, China began an economic overhaul that led to the dismantling of the entire system. Government subsidies were cut drastically, and hospitals had to come up with ways to generate profits. [Source: Siu-wee Lee, New York Times, September 30, 2018]
To address concerns over health, the Chinese greatly increased the number and quality of health-care personnel, although in 1986 serious shortages still existed. In 1949 only 33,000 nurses and 363,000 physicians were practicing; by 1985 the numbers had risen dramatically to 637,000 nurses and 1.4 million physicians. Official Chinese statistics also reported that the number of paramedics increased from about 485,400 in 1975 to more than 853,400 in 1982. [Source: Library of Congress]
Efforts were made to improve and expand medical facilities. The number of hospital beds increased from 1.7 million in 1976 to 2.2 million in 1984, or to 2 beds per 1,000 compared with 4.5 beds per 1,000 in 1981 in the United States. The number of hospitals increased from 63,000 in 1976 to 67,000 in 1984, and the number of specialized hospitals and scientific research institutions doubled during the same period.
Rural Health Care in China in the 1980s
The availability and quality of health care varied widely from city to countryside. According to 1982 census data, in rural areas the crude death rate was 1.6 per 1,000 higher than in urban areas, and life expectancy was about 4 years lower. The number of senior physicians per 1,000 population was about 10 times greater in urban areas than in rural ones; state expenditure on medical care was more than -Y26 per capita in urban areas and less than -Y3 per capita in rural areas. There were also about twice as many hospital beds in urban areas as in rural areas. These are aggregate figures, however, and certain rural areas had much better medical care and nutritional levels than others. [Source: Library of Congress]
“In 1987 economic reforms were causing a fundamental transformation of the rural health-care system. The decollectivization of agriculture resulted in a decreased desire on the part of the rural populations to support the collective welfare system, of which health care was a part. In 1984 surveys showed that only 40 to 45 percent of the rural population was covered by an organized cooperative medical system, as compared with 80 to 90 percent in 1979.
“This shift entailed a number of important consequences for rural health care. The lack of financial resources for the cooperatives resulted in a decrease in the number of barefoot doctors, which meant that health education and primary and home care suffered and that in some villages sanitation and water supplies were checked less frequently. Also, the failure of the cooperative health-care system limited the funds available for continuing education for barefoot doctors, thereby hindering their ability to provide adequate preventive and curative services. The costs of medical treatment increased, deterring some patients from obtaining necessary medical attention. If the patients could not pay for services received, then the financial responsibility fell on the hospitals and commune health centers, in some cases creating large debts.
“Consequently, in the post-Mao era of modernization, the rural areas were forced to adapt to a changing health-care environment. Many barefoot doctors went into private practice, operating on a fee-for-service basis and charging for medication. But soon farmers demanded better medical services as their incomes increased, bypassing the barefoot doctors and going straight to the commune health centers or county hospitals. A number of barefoot doctors left the medical profession after discovering that they could earn a better living from farming, and their services were not replaced. The leaders of brigades, through which local health care was administered, also found farming to be more lucrative than their salaried positions, and many of them left their jobs. Many of the cooperative medical programs collapsed. Farmers in some brigades established voluntary health-insurance programs but had difficulty organizing and administering them.
Health Care in Crisis in the 1990s
A major reform of China's health system was undertaken in 1990s to manage serious diseases and revamping inefficiencies. The Ministry of Public Heath's ninth five-year plan on the control of serious diseases outlined major initiatives to be reached by the year 2000. These included strengthening epidemic prevention management systems and facilities. Needless to say these goals were not satisfactorily reached. [Source: Worldmark Encyclopedia of Nations, Thomson Gale, 2007]
By the 1990s, China's healthcare system was “in crisis” and, with only 10 percent of the population entitled to benefits, it ranked 188th out of 191 countries in a World Health Organization (WHO) equality report. Subsequent government attempts to develop an employee-employer co-funded insurance scheme were of limited success, and by 2005 had achieved only 40 percent coverage. The government's response was to increase healthcare spending by 87 percent over the next two years - a monumental rise - and to outline plans for a national healthcare system by 2020. Further spending hikes and regulatory changes have followed, particularly as part of last year's economic stimulus plan. Spending in 2010 is up another 8.7 percent, with about 4.5 percent of gross domestic product (GDP) allocated to healthcare, half of which comes from the private sector.
Poor Health Care in Rural China
Taoist god of medicine
Rural areas lack adequate public-health services. About half of China's population lives in the countryside, but about 80 percent of China’s medical facilities are concentrated in cities. A study published in the Lancet in 2010 showed children born in rural China were three to six times more likely to die before they turn five than those born in cities.Many rural people rely on local health care that is often in the form of ill-equipped clinics and local healers. There are no ambulances or 911 numbers. People often have to walk, sometimes for days, to get to a decent clinic or hospital. People with medical problems often can do nothing about them because they can't afford medicine or a visit to the doctor.
In the 2000s, according to Chinese government, 79 percent of rural Chinese were uninsured while more than half of urban residents had some kind of coverage, most of which was supplied by their employers. Howard W. French wrote in the New York Times: “The near total absence of adequate health care in much of the countryside has sown deep resentment among the peasantry while helping to spread infectious diseases like hepatitis and tuberculosis and making the country — and the world — more vulnerable to epidemics. [Source: Howard W. French, New York Times, January 14, 2006]
“The recent emphasis on profit, meanwhile, has led doctors and other well-trained health care workers to abandon the countryside, with a result that peasants are left at the mercy of unqualified caregivers and outright charlatans who peddle expensive, improperly prescribed drugs and counterfeit medicines. "From the liberation to the Cultural Revolution, conditions in the rural areas were fairly good," Dr. Wang Weizhong, a physician and member of the National People's Congress from Jilin Province in the northeast, said of the period from 1949 to the 1970's. "There were township clinics in every area, and there was no problem getting at least small illnesses treated everywhere." Dr. Wang insisted that the government was working hard with its recent health care reforms to address the problems, but agreed that the old public health system that once protected peasants "had dissolved."
“Unable to afford proper care, the first recourse of most peasants when they fall ill is to take whatever drugs they can find on the market to relieve their symptoms and hope that their ailment goes away. Often, of course, they merely get worse or, if their illness is communicable, spread it to others. Once a peasant's illness becomes debilitating, his relatives can face a double catastrophe: the serious decline of a breadwinner, and medical bills steep enough to bankrupt the family. "I've visited many villages that are really very poor, and reading the doctors' records you can see people unable to pay the clinic only two yuan or five yuan," or 25 to 60 cents, said He Congpei, an expert on health care in rural China with the Amity Foundation, a Chinese independent organization that promotes rural health care and development.
Rural and Village Health Care in China
Many people don’t practice rudimentary disease prevention measures such as keeping water covered, washing vegetables, brushing teeth, vaccinating children, taking the garbage away from the house and screening windows against flies and mosquitos. In small villages self-taught healers often serve as doctors with villagers only seeking out hospitals — often multi-hour journeys away — when they have a serious illness. One such healer told the China Daily, “I am not a qualified doctor, but I know how to handle small health problems.”
The village healers methods include tendon stretching and “scraping away fever.” Among the books he swears by are “Rely on Yourself Not Doctors” by Zheng Fuzhiong, “Decoding the Inner Canon of the Yellow Emperor” by Qu Limin, “The Tao of Chinese Medicine” by Yie Housheng, and “Users Guide to the Meridians and Collaterals in the Human Body” by Xiao Yansheng.
Describing the treatment at a Chinese hospital for a friend who was bitten by a snake with tissue-eating venom Peter Hessler wrote in The New Yorker, “A doctor sliced open the bitten finger. They had some traditional Chinese medicine; Goettig figured it was a good sign that the box showed a picture of a snake. The doctor used a mortar and pestle to grind up the pills, and then he shoved the powder directly into the incision,...The swelling continued to spread. Goettig’s arm turned purple at the joints where the venom ruptured capillaries...The next day, the doctors cut open the hand three times to shove more powder inside. The pain was intense...After the third day, the swelling began to subside. He stayed in the hospital for a week...His hand recovered fully.”
Health Insurance in China
In the late 2000s and 2010s China rolled-out a basic system of state-backed medical insurance covering 95 percent of the population. Before that one fourth of China’s population — over 300 million people — had no health insurance. People with no insurance avoid seeing doctors, knowing that is quickest way to go broke. Even when people have insurance, insurers rarely pay out more than a couple thousand dollars. A nationwide insurance roll-out was launched in 2009. It has made people more likely to see doctors and made treatment much more affordable. Almost nine percent of people stayed in a hospital in 2011, from less than four percent in 2003, a study published in The Lancet showed.
Most Chinese are covered by health care that covers 40 percent to 90 percent of health cost. Under the system families were required to pay the bill and then were reimbursed afterwards, a process that was often a burden on the poor. Payment is often slowed and complicated by bureaucratic red tape, putting families at risk of bankruptcy when major health problems occur. Under this system, the government pays around 60 percent of hospital expenses but contributed virtually nothing for medications and outpatient services.
Families of a sick or handicapped child received a monthly stipend of 80 to 100 yuan once the mother reached the age of 49. Some cities and provinces provided additional subsidies and coverage. Companies and individual could purchase private insurance policies. State urban plans often only covered individuals in their home cites. If they traveled to another city and need help they were not covered. A 34-year-old editor who had commercial health insurance in addition to state coverage told the Washington Post she paid for the first $300 of the cost for her treatment for a recent bout of pneumonia and insurance covered 90 percent of the next $750. Coverage for children often only applies if the children were hospitalized. Expenses outside the hospital which can run into the hundreds of dollars were not covered.
Zhang Shuo, a senior Health Specialist with the World Bank's Beijing office, told Reuters that China's health care insurance system is a fragmented one, mostly coordinated within counties. Figures from the Ministry of Human Resources and Social Security in 2012 showed that only about 20 percent of migrant workers have health insurance. ""Health insurance works locally, but when we go work in other places, only some provide health insurance, which still requires a lot of procedures. And each could take months and still wouldn't come through," Cao Yong, a migrant worker delegate to parliament, told state radio. [Source: Hui Li and Ben Blanchard, Reuters, March 27, 2013]
History of Health Insurance in China
Until the early 1990s , medical care was provided through the work unit system which funded care out of its operating income. The Chinese National Petroleum Company, for example, once ran more than 50 hospitals for its 1.5 million workers. When economic reforms kicked in many of these state-owned companies found they had enough trouble being viable as profit-making companies and were unable to pay for health care cost for employees and retirees on their pension plans. [Source: Steven Mufson, Washington Post, October 2009]
Under the old system implemented in the planned economy, “the labor insurance system” provided that all the “socialist workers” get healthcare from the state for free, with children’s healthcare covered through their parents’ "labor insurance". According to article 13 of The 1950 PRC Regulation on the Labor Insurance, a worker’s medical bill shall be paid by the state-owned enterprises for which he or she works, and their children get fifty percent of their medical costs reimbursed. [Source: Library of Congress Law Library, Legal Reports, 2007 |*|]
In 1994, the State Council overhauled the system by placing urban workers in city wide insurance pools that embraced around 200 million of China’s 1.2 billion people at that time. Hospitals and industrial enterprises severed their ties. Instead employers contributed 6 percent of wages and employees 2 percent to cover medical costs. The system failed to provide descent health care. Out of pocket expenses increased dramatically, far exceeding per capita income and national health expenditures.
The labor insurance was replaced by “the employee’s basic medical insurance” in 1998. The State Council of China issued The Decision on Establishing the Urban Employees’ Basic Medical Insurance System at the end of that year. Children’s health care is not covered in this decision, which actually pushes them out of the state’s medical insurance system. The State Council is now considering a new medical insurance system, aiming to cover children and other citizens who are not eligible to join the employees’ basic medical insurance. Local governments, especially those in developed areas, are establishing local medical insurance systems for the children residing in those areas. |*|
The government went from paying 90 percent of medical expenses in the early 1990s to 17 percent in the mid 2000s. According to the World Bank, the number of Chinese with access to state facilities shrunk from 71 percent to 21 percent between 1981 and 1993 and out-of-pocket expenses for medical care increased 100 times between 1980 and 2005.
Improving Health Insurance in China
The Chinese government has made setting up adequate health insurance a top priority. There is a plan to establish community insurance pools and programs in which workers are forced to put a percentage of their income in an individual medical account. China was heavily engaged in reforming the health care system in the 1990s and 2000s. One of the aim of the health care program approved in 2009 is to provide some form of medical insurance for 90 percent of the population by 2011. Each person covered by the system would receive an annual subsidy of more than $17 starting in 2010. Medicine would also be covered by the insurance, and the government would begin a system of producing and distributing necessary drugs this year.
To build a country-wide healthcare reimbursement system is our goal, but there is still quite a long way to go," Hu Xiaoyi, vice minister of Ministry of Human Resources and Social Security said in 2012. In 2003, the Chinese government gave more money to rural medical cooperatives and set up a system in which farmers put in $3 a year and the government provided a $12 subsidy for coverage of 25 percent to 30 percent of hospital expenses but little for outpatient care. The coverage doesn’t sound that great but 850 million enrolled n it. Between 2009 and 2012 the government plans to increase its contribution by half.
In 2007, the government extended coverage to urban workers and families who had been without coverage since the end of the 1994 collapse of the work unit system. Children, elderly, migrant workers and the unemployed all qualified for the same $12 subsidy received by rural people but because health care costs are higher in the cities than rural areas, urban people have to contribute more than $30 — instead of $12 — a year. About 120 million people have signed up for this.
In 2009, government pledged to spend $123 billion over three years to deliver basic health care and health insurance to 9 out 10 Chinese. The law calls for a revamping of hospitals and providing better services at lower cost. One of the hopes of the program is that it will help generate growth by getting people to spend more money by removing the need to save money for a medical problems.
"Health care insurance and other social insurances are closely linked to hukou" — the official document issued by the Chinese government saying its holder is a legal resident of a particular area and a handicap for people, particularly migrant workers, seeking benefits like health care outside their home areas. "Providing better social insurance is, I believe, an incentive to reform hukou system", said Zhang Shuo, a senior Health Specialist with the World Bank's Beijing office. "China's urbanization will be unprecedented in speed and scale," Zhang explained, "Portable social insurances is key to encourage labor migration, but it will take some time for a country as big as China."
Image Sources: Wiki Commons, University of Washington; Harvard Public Health; Nolls China website http://www.paulnoll.com/China/index.html
Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, National Geographic, The New Yorker, Time, Newsweek, Reuters, AP, Lonely Planet Guides, Compton’s Encyclopedia and various books and other publications.
Last updated September 2022