The New York Times 14 March 2001 Without 'Barefoot Doctors,' China's Rural Families Suffer By Elisabeth Rosenthal BAZUO, China - As Zhang Youlian wept in the dirt courtyard surrounded by towering peaks, her tears spoke to her year of calamities. First, her 35-year-old husband fell ill and was taken from their rice fields to the hospital with chest pain that he had ignored for too long. Then, her 4-year-old caught his hand in a thresher. Covered with blood and cradling the wide-eyed boy in her arms, she stumbled down miles of steep rocky paths until she found a car that drove them to a doctor. Her husband died in the emergency room. Her son is now missing half his hand. And her personal losses have been compounded by unthinkable debt. Although neither patient was admitted to the hospital, bills for their treatment totaled more than $500, seven times the average yearly income here in their village in southwestern Yunnan Province. And, as with most rural families, there was neither medical insurance nor welfare benefits to cover the costs. "I borrowed it from family members," Ms. Zhang said. "I don't know how I'll pay it back." Huge numbers of China's 800 million rural residents are in a medical free fall, as the once-vaunted system of "barefoot doctors" and free rural clinics has disintegrated over the last decade, a side effect of successful market-oriented changes. As central government planners have withdrawn from people's lives, they have taken with them most subsidies for social services like health and education, hoping that local coffers and initiatives would fill the gap. They have not. The rural health system has become a hodgepodge of hospitals and clinics that are often privately run and almost always prohibitively expensive, where treatment for a cold can eat up two months' income and giving birth in a hospital two years of hard-earned cash. With health costs that increased 400 to 500 percent from 1990 to 1997, according to a new United Nations report, medical care in many rural areas is so costly that people have stopped seeing doctors except in extreme emergencies. The ill endure pain, chronic infection and the risks of childbirth at home. Illness is the leading reason why Chinese families fall below the poverty line, researchers say. "If you are really sick, you borrow and go to the doctor," a neighbor of Ms. Zhang, Chen Jiuxiang, said. "But most people still don't want to go, because we are poor here and they know it will cost a fortune. Twenty years ago it was different. It was easy to see the doctor and cheap, too. Even if you had to go to the hospital with a very serious illness, it would cost at most 100 yuan," or $15. Health statistics are beginning to reflect the large numbers who now do without. The number of tuberculosis cases has quadrupled in 15 years, and infant mortality, which had been declining steadily for most of 40 years, is beginning to creep up in poor areas, according to the United Nations report, which has not been officially released. Although government outreach programs in remote areas once gave China immunization rates that were the envy of the developing world, the effort has started to slip. "Coverage is uneven in poor areas such as Shanxi and Guizhou Provinces, where measles coverage is as low as in many sub-Saharan African countries," the report said. Many Chinese echo that assessment. "China is not achieving its own basic health criterion," said Prof. Zhu Ling, an economist at the Chinese Academy of Social Science who has been studying health care. "People aren't getting basic health services because they can't afford them." Dr. Nie Chunlei, deputy director of the Rural Health Division in the Health Ministry, emphasized that indicators had continued to improve for the country as a whole. Infant mortality decreased throughout the 1990's, and almost 90 percent of villages have at least one clinic. But Dr. Nie acknowledged that "development has been very imbalanced," with poor farming areas and less-developed western provinces left behind. "In very poor places," he said, "the government and the collective don't have the money to subsidize health care, and so the peasants have to pay it all. In many cases, they don't have the money to see a doctor." In cities and more prosperous coastal farming areas, health care has improved in the last decade, with government hospitals offering more sophisticated tests and specialized medicines. Still, even in cities, just a minority of residents has comprehensive coverage, and nearly everyone grumbles about increasing costs. The situation is far more dire in the vast poor rural regions, where local officials had neither the money nor expertise to maintain a health system after central government assistance had dried up. Many areas simply cut loose government clinics and hospitals, requiring them to support themselves. Today in rural areas, an increasing number of clinics are privately owned for-profit ventures that set their own rates, and even state-owned clinics are often contracted out. "In some provinces, there is no system left, and it's every man for himself," said a Chinese health expert who works at a state research institute. The Health Ministry has acknowledged the problem and has helped local governments develop pilot projects to address it. But budget cuts have reduced its staff by 45 percent since 1998, and there has been little concrete progress. The government still limits the doctors' consultation fees to 60 cents a visit, a sum that has not changed for decades despite inflation. But there is little regulation of charges for medicines, injections and tests, which are prescribed in abundance. Market forces have brought modern medical technology into the countryside. Clinics in remote rural villages now dispense a wide variety of Western drugs. Even small county hospitals have CAT scanners. But in poor places like Bazuo, such fruits of progress are generally out of reach. The United Nations report said even a simple hospital stay could cost more than the yearly income of most peasants. Song Youzhi never saw a doctor when she was pregnant with Wang Xiaorui, now 3, because, she said, "I felt O.K." When contractions began, she stayed at home and gave birth with the help of a relative. Nearly all the women in Bazuo give birth without prenatal care, in unheated houses with no running water. Some are deterred from seeking medical help because their mud-brick houses are hours away by footpath from the dirt road that zigzags down the mountain to the township hospital. But for others like Ms. Song, who lives quite close to the hospital, the issue is money. "Of course, it's safer and more comfortable in the hospital," Ms. Song said. "But it's too much money - 600 to 700 yuan. And I didn't have that." She added that her family earned $60 a year growing ginger and red peppers. By discouraging expectant mothers from seeking professional help, such fees have contributed to high rates of infant mortality and women's deaths in childbirth. In the county that includes Bazuo, children died before their 5th birthday at a rate of 64.7 per 1,000, twice the national average. In some parts of Yunnan Province, the rate is as high as 200 per 1,000, meaning that one of every five children will die before turning 5 years old. Although the Health Ministry would like all women to give birth in hospitals, the United Nations report estimates that 29 percent of women in poor counties can afford prenatal examinations and that 6 percent can afford hospital deliveries. In counties where pilot projects have reduced hospital charges for childbirth, the percentage of hospital deliveries has more than doubled. But experts say many women are reluctant to spend any money in rural health centers because conditions are often poor. Chinese health researchers say the new market-driven care offers few advantages to hundreds of millions of rural poor. And, they say, the new setup fails at tasks that the old system performed so well like public health campaigns and immunization drives. Self-supporting clinics cannot make money trekking out to distant villages to vaccinate children or exhorting women to obtain prenatal care, they said. Although Dr. Nie of the Health Ministry said immunization rates remained very high, he added that in remote areas the lack of vaccinations was becoming "a very serious problem." Although a basic immunization set is still technically free, patients often pay "administration fees," as well as fees for needles and syringes. No new immunizations have been added to the free program since 1978, not even hepatitis B vaccine, which would help fight a disease that is endemic in China. Professor Zhu, the economist, has proposed that the central government allocate money from its antipoverty program to underwrite rural care. Some basic and preventive services need to be free for poor people, she said. Otherwise people will not receive them. At the urging of the central government, additional cities and prosperous rural counties, where farm income is supplemented by small businesses, are developing fledgling insurance plans or cost-sharing programs, under which a local government may pay parts of medical bills, Dr. Nie said. But even there, the local governments contribute at most half the cost, and Dr. Nie acknowledged that the model would not work in much of the country. "Finance is a very difficult question," he said. "We've been thinking a lot about this in the last two years. But the central government doesn't have the resources to solve this alone. It can't bear the cost."
