China’s Declining Health

DAOYUAN VILLAGE, China —  Bao Fengxiang watched helplessly as migraines gripped her son in a vise so tight around his skull that he sweated in pain. Worried about the health of her family’s only male heir, she dragged the 13-year-old to a hospital two hours away from home to determine what was wrong.

They returned here none the wiser--but considerably poorer. After conducting a battery of tests, doctors told Bao that they could not diagnose the cause of her son’s headaches. Then they charged her the equivalent of about $120--half her household’s annual income--for their services.

She scraped together the cash by selling off her yearling pigs. Along with them went any hope of savings or profit from her family farm in southern China’s Yunnan province.

“There’s nothing you can do,” said Bao, 36, resigned to seeing her son suffer ebilitating relapses every few months without effective treatment. “Now we eat what we grow and sell less.”

The drain on Bao’s household finances because of medical costs is a phenomenon replicated in millions of rural households across the world’s most populous nation. In the 20 years since market reforms began dismantling the vast agricultural communes that stood at the heart of Maoist philosophy and provided cradle-to-grave welfare, most farmers have been forced to dig into their own shallow pockets to pay for everything from child immunizations to major surgery.

Public-health experts are just beginning to gauge the consequences of the shift away from the collective system--and they are increasingly alarmed by what they see. Too poor to afford services once offered virtually free, rural residents routinely delay medical treatment, receive substandard care or forgo preventive services to save money. This shift has led to a quiet deterioration in public health that has gotten lost in the glare of media attention to China’s astonishing economic gains.

Roundworm and other eradicable parasites are endemic in the countryside; as many as 90% of children in poverty-stricken areas suffer from chronic worm infections, according to the World Bank. Dysentery afflicts millions. Tuberculosis, once well-controlled, and typhoid plague the rural poor, as do sexually transmitted diseases.

After years of encouraging declines, the mortality rate for children younger than 5--a key marker of a nation’s health--appears to have leveled off, and is even rising in some places. The life expectancy rate too has stopped improving, traceable in part to the demise of low-cost medical care, experts say.

“I believe strongly that the collapse of the cooperative health system has had an adverse effect on the health of the Chinese rural population,” said William Hsiao, a professor of health economics at Harvard University who has researched and written about the issue.

Although Chinese health officials recognize the problem, observers say, the central government has been too preoccupied with keeping order and economic growth in the cities to address the health-care woes of the peasants who once formed the cornerstone of Communist ideology.

“The rural population has a very small voice in national politics,” Hsiao said. “The top national leaders worry about riots in the cities, which may involve tens of thousands, but not the small demonstrations in the countryside.”

700 Million Lack Resources for Care

The sheer magnitude of China’s rural health-care problem almost beggars the imagination. While 43 million Americans lived without medical insurance in 1997, according to the U.S. Census Bureau, about 700 million Chinese farmers--more than 2 1/2 times the entire U.S. population--lack resources to deal with illness or injury.

Experts credit China with impressive strides in health standards since the 1950s. The average citizen, who was lucky to live past 40 when the People’s Republic was established in 1949, can now expect to survive to about 70. Access to basic health services has improved drastically, with nearly 68,000 hospitals across China, up from 2,600 half a century ago.

But progress in physical well-being has not kept pace with the rise in income and wealth over the past two decades, analysts say. “If you took another country in something like China’s circumstances 15 or 20 years ago and looked at where they are today, I think most countries would be doing substantially better than where China is today,” said Dean Jamison, who teaches international health economics at UCLA and works with the World Health Organization.

“China still does very well relative to its income level and the health of its population,” he added. “[But] in the ‘70s, at a time when the rural cooperative system was in place, they were doing even better.”

Back then, villagers like Bao relied on their communes to meet all their medical needs, part of a cooperative health system set up by local Communist Party officials in the early 1960s.

During the radical 1966-76 Cultural Revolution, thousands of minimally trained “barefoot doctors” were dispatched to the countryside. Immunization spread throughout China. The state subsidized almost everything.

“When I was a kid, we only had to pay 5 jiao [about 6 cents now] to register” with a medic or doctor, recalled Bao, knotting a shawl around her with weather-beaten hands. “Everything else was free.”

By the mid-1980s, however, most of the big farming collectives had vanished under reforms that allowed families to till their own plots of land. The medical cooperatives--deprived of their community funding--disappeared as well, abandoned in 90% of rural areas.

Now, peasant farmers must pay for the services of village “doctors,” who wear shoes but often boast little more education than their predecessors--through junior high school, with perhaps a dash of vocational medical training.

“If you take these doctors and put them in Africa, you might say they’re quite good. But put them in a developed country, and you’d say, ‘What is this? They’re not entitled to be a doctor,’ ” said Zhang Jingfang, a Chinese physician who works with the international humanitarian group Doctors Without Borders to train rural medics in Yunnan province.

Village health workers, about 1.3 million in all, remain the foundation of the rural health-care system and the farmers’ first resort when illness strikes. But in stark contrast to the barefoot doctors, who were provided and paid by the state, funding cutbacks have forced present-day village medics to operate essentially as private practitioners who subsist on charging fees and selling drugs to patients to supplement their meager state stipends.

Here in Daoyuan Village, a hamlet of about 4,000 people in one of China’s officially designated “poor counties,” medic Yang Guanding receives the equivalent of about $7.25 a month from the township and county authorities.

Medic Taught Herself the Basics

The 35-year-old Yang has been practicing medicine for half her life. Forbidden by her parents to enroll in high school, she taught herself the basics by sending away for medical textbooks. A couple of vocational seminars in a nearby town, and her recent completion of Doctors Without Borders’ three-month basic training course, make up her formal medical education.

Nevertheless, villagers flock to her for relief from colds, diarrhea and other minor ailments. So do pregnant women: Yang handled at least 30 births and 19 abortions over a recent four-month period in her makeshift surgery ward, according to her meticulous records.

Yang, a frank woman with a ready smile, is popular among her patients because she allows them to defer payments they can’t afford--a situation that applies to as many as two out of three people who come calling, she says. About 10% pay nothing, too poor to shell out the equivalent of a few cents for some aspirin.

Zhu Azhen, 26, managed to scrounge up the money she owed for nine visits to the medic. Most of the visits were for her 2-year-old daughter, who suffers from recurring pneumonia and diarrhea.

On a large wooden abacus, Yang’s nimble fingers added up the outstanding bills: about $9, more than one-tenth of Zhu’s yearly household income from her struggling tobacco farm.

“The doctor is very nice,” Zhu said fervently. “She treats you whether you have money or not. I went to the county hospital to get the diarrhea treated, and the care was good, but there they won’t treat you unless you can pay.”

Other patients waited with Zhu inside Yang’s two-room clinic for the medic’s attention: young mothers with sniffling toddlers, elderly women with bound feet complaining of rheumatism, and a few villagers hot with fever. They sat on tiny stools or on two rickety metal sickbeds covered with grimy blankets where weaker patients receive intravenous drips from bottles suspended from a string stretched across the room.

For almost every patient, Yang prescribed an injection of some sort. “A lot of old people, if you don’t give them a shot, psychologically they don’t feel like they’ll get better,” she explained. Empty vials littered her windowsill, drained of medicine ranging from mild painkillers to liquid vitamin B.

Yang buys her drugs from a state-owned pharmaceutical firm with her own money, then passes the cost on to her patients at a legally permitted 15% markup.

For many rural health-care providers, prescribing hefty quantities of medicine is the only way to make ends meet. More than 50% of all health spending in China in 1993, from state and individual sources, went toward the purchase of pharmaceuticals, far more than the 5% to 20% in developed countries, according to the World Bank.

“These village doctors have basically become drug peddlers because they rely on selling drugs to generate income,” said Harvard’s Hsiao. Overprescription of antibiotics and more expensive drugs is common, which can impoverish sick villagers.

Yang’s bare-bones operation is not equipped to deal with more threatening illnesses. Most village clinics count themselves lucky to have the “three essentials”: a stethoscope, thermometer and blood-pressure gauge. Serious cases are referred to township or county hospitals.

But villagers often are loath to make the pilgrimage. “One hospital admission can bankrupt a family,” Hsiao said. “The cost of hospitalization is the No. 1 ‘poverty generator’ in many rural communities, since one episode of hospital stay would require a family to use up their savings, sell their seed for the next season and borrow.”

Afraid of being wiped out financially, many farmers avoid seeking medical care altogether. A survey five years ago found that 41% of ill farmers neglected to seek hospitalization because they considered it too expensive.

Such behavior has brought signs that some of the considerable gains China made in public health conditions over the past half a century may be unraveling, international experts say.

Child Mortality Rate Concerns Experts

One key indicator, the mortality rate of children younger than 5, has especially concerned health professionals. In 1985, China reported an under-5 mortality rate of 44 per 1,000 live births, an impressive 75% drop from the 1960 rate of 173 deaths per 1,000, according to the World Bank.

But experts say the rate then leveled off--about the time that free health care through the cooperatives was eliminated--instead of continuing to drop. By contrast, Japan’s under-5 mortality rate is only six deaths per 1,000 live births.

“There were two things going on that suggested it should have gone down quite sharply,” said Jamison at UCLA. “One is the rising income level [across China], and two, the world is just doing a lot better in terms of under-5 mortality. China doesn’t appear to be participating in those gains despite its income growth, which is enormous in the period of the early ‘80s to the early ‘90s.”

The central government’s Ministry of Health disputes the figures, saying the under-5 mortality rate continued to fall in the ‘90s. Ministry officials declined to be interviewed.

The evidence recorded in a careful hand on a framed chart in Chengguang township, which oversees Daoyuan Village, is not encouraging. Over the past three years, the number of children who have died before entering kindergarten has risen dramatically, from about 58 per 1,000 live births in 1995 to 78 per 1,000 last year.

Local officials are vague about what caused the jump. Dysentery has been a severe problem of late, they acknowledge. Pneumonia and other respiratory infections, along with hepatitis, are widespread. Malnutrition is also a scourge in poor areas such as Chengguang, resulting in stunted growth and deficiencies of iron and vitamin A.

To protect rural families against financial disasters brought on by illness and injury, international health experts urge the Communist government to again set up cooperative-type medical systems, at least until a more sophisticated insurance plan can be developed, and to devote more resources to rural health care. As it is, urban areas, home to just 30% of the population, suck up the lion’s share of public-health funding--twice that of the countryside, according to figures from 1993.

Premier Zhu Rongji announced earlier this year that health-care reform would be one of the country’s five major reform priorities, but no plans have yet been unveiled. China’s State Council, which controls the Ministry of Health, “has not been willing to do anything meaningful, other than give some lip service” to improving rural public health, Hsiao said.

A few outposts have experimented successfully on their own with different models of cooperative care, which foreign and domestic experts hope can be duplicated in other areas. Farmers seem to embrace the idea: Surveys in parts of Hubei and Henan provinces showed that at least 90% of villagers polled wanted to pool their risk, the China Daily reported a year ago.

But Zhang, the physician who works with Doctors Without Borders, views the situation with a dose of cold-eyed realism. “It’s not that [the government] doesn’t want to take care of this, but you can’t do everything at once,” she said.

She predicts an eventual return to a cooperative health system, though it “cannot be free, as it was before,” and would probably cover only basic services, not major emergencies. For that, peasant farmers will still have to depend upon the kindness of family and friends to see them through.

“It all boils down to money,” Zhang said.