In Rural China , Health Care Grows Expensive and Elusive

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In Rural China , Health Care

Grows Expensive and Elusive

By Peter Wonacott
The Wall Street Journal, May 19, 2003

[People's Burden] TAIYUAN, China -- Suffering from a fever and pneumonia, Liu Ruiqiang, a 31-year-old farmer from a small nearby village, was turned down by three hospitals last month. Some staff even refused to take his temperature for fear of being infected with severe acute respiratory syndrome.

When a fourth, the No. 2 Hospital of Shanxi Medical University here in this northern Chinese city, did decide to admit Mr. Liu, it asked for a deposit of $724 in yuan, according to his family and hospital registration workers who confirm the deposit as standard practice. The average annual income for a rural resident in China is $286.

Like the vast majority of China's 700 million rural residents, Mr. Liu has no insurance. The hospital agreed to admit him for a daily fee of $60 instead, which he was able to pay after his mother raised money in his home village. But after four days, he sneaked out of the hospital, bought a bus ticket and fled home, to escape the cost of his care.

"We are really poor," said Mr. Liu's father, Liu Shufa. "We can't afford to get sick."

In contrast to dramatic improvement in other parts of everyday life over the past 20 years, health care in China's new profit-oriented economy has been declining sharply. And now as China struggles to combat the SARS epidemic, the Chinese are relying on a crippled health-care system that covers far fewer people than it did decades ago.

The decline is hitting hardest in China's rural areas, heightening the danger of faster transmission of SARS in vast parts of the country. Under Mao Zedong, China nearly accomplished the utopian goal of full medical coverage in the countryside. In 1975, about 85% of rural residents had community-financed health care, under a commune system. Today, about 10% do. Although the government now says it's picking up the tab for the treatment of confirmed SARS cases, confusion over the new policy introduces an odd dilemma: Patients who seek treatment and don't have SARS could be stuck with the bill.

As part of its economic reforms, the Chinese government has been steadily cutting the percentage of funds it spends on health care, shifting more of the cost onto its citizens. In 1991, for example, 39% of China's total health-care expenditures came out of the pockets of individual citizens. By 2000, individuals paid for 60% of the nation's health-care costs.

In rural areas, the difference is particularly striking. Through the 1990s, farmers' incomes roughly tripled, but medical costs soared more than eightfold, according to Wang Yanzhong, an expert on rural public health at the Chinese Academy of Social Sciences. Three years ago, the World Health Organization ranked China 188 out of 191 countries, in terms of "fairness" of government contributions to health-care costs. "Public health in China is extremely weak," says Henk Bekedam, chief representative in China for the WHO. "In many aspects, it is worse than it was 20 years ago."

In the early 1980s, Deng Xiaoping's reforms dismantled the communist health-care model. With economic growth the new orthodoxy, China introduced one of the world's most commercial medical systems. Central and local governments put money elsewhere, and decided hospitals should support themselves. Many hospitals now demand patients pay up front before providing care.

As immunization and other prevention programs have fallen by the wayside, diseases have become more difficult to fight. Today, China has the second-highest number of people in the world suffering from tuberculosis, after India, with the disease killing 130,000 Chinese every year. In addition, China has an estimated 1.5 million people with HIV/AIDS. Last year, the United Nations predicted the number of such cases in China would climb to 10 million by 2010.

Most village medical workers, once known as "barefoot doctors," aren't trained to treat serious ailments. County doctors, the next level, are usually young and underpaid. The typical big-city doctor, earning $600 to $1,200 a month, may see 60 to 80 patients a day -- more than double the average load of an internist in the U.S., medical experts say.

With government support dwindling, hospitals are increasingly relying on drug sales to subsidize operations. Rural health centers are so strapped that 60% of their revenue comes from drug sales, according to China's health ministry. Many doctors count on the sales for their income, and some even boost profits by selling fake medicine, says William Hsiao, an economist at the Harvard School of Public Health, who has spearheaded research in several Chinese provinces. "The village doctors have largely become drug peddlers," he says.

Chinese officials say progress has been made in many areas of health care, and that local medical workers are better trained than in the past. The government recently earmarked about $350 million to establish disease control and prevention centers in poor areas. Even pre-SARS, the Chinese government was starting to acknowledge the severity of the rural health crisis. In October, it unveiled a plan to extend health-care subsidies to rural residents.

Last week, Vice Minister of Agriculture Liu Jian conceded China faces difficulties fighting SARS in rural areas, because of "inadequate medical resources," among other problems.

Chinese farmers now fear medical bills almost as much as they do SARS. At one county hospital outside of Taiyuan city, in an area where residents subsist growing potatoes and millet, most patients manage to avoid paying even a three-cent registration fee. For those who do, when lab tests or chest X-rays are ordered -- critical in diagnosing SARS -- patients tend to disappear. The $6 charge is out of reach for most.

Care is primitive. Consultations at the county hospital outside Taiyuan hospital are carried out in a room with no running water, just a wash basin to keep hands clean. When the hospital had to satisfy a government request last month to set up a fever clinic to isolate suspected SARS patients, staff placed a wooden table outside in a courtyard under a tree.

The hospital is now building a separate ward with fresh funding from the county government, but other problems have undermined the battle against SARS. There is a shortage of sterile clothing for staffers. A respirator arrived recently, but nobody seems to know how to use it. "If there was a major outbreak, we'd be in trouble," says Alice Chen, a Canadian doctor working in the hospital.

Given the poor state of such hospitals, the best hope for controlling the spread of SARS may rest on mass mobilization that resembles the political campaigns of the 1950s and 1960s. Across China, officials are sealing off villages, patrolling streets and poking into homes to monitor the health of residents. The government has even threatened to arrest and execute people who knowingly spread SARS.

The draconian measures come as new cases decline and hopes rise that SARS can be contained before it spreads in the countryside. As of May 12, there were 155 confirmed SARS cases in rural areas, or 6% of the total in China, according to Chinese government officials. Sunday, China reported two SARS deaths -- the lowest daily figure since April 20, when its health ministry started regularly reporting cases, after acknowledging that a large number had been covered up.

However, the WHO has remained critical of China's accounting of the virus. In a statement released over the weekend, it warned that some doctors were misdiagnosing patients, which could explain the lower number of probable cases in recent days. China has 5,233 confirmed SARS cases and 284 SARS deaths, according to a government tally released Sunday.

For Mr. Liu, the farmer who fled the hospital, returning home put his family in a perilous situation. When he arrived in his village of Xiguan, neighbors were frightened to come out of their homes, says his mother, Meng Rongqing. Two hours later, she made a wrenching decision: She reported her son to local health authorities. Mrs. Meng called Qingxu county's Center for Disease Control three times before they answered, she says, but eventually a worker talked to her son, and persuaded him to return to the hospital. A convoy of vehicles arrived, including an ambulance that took Mr. Liu back to the No. 2 Hospital of Shanxi Medical University.

He remains there. The Qingxu Center for Disease Control says Mr. Liu became a confirmed SARS patient May 9, according to Jiang Yunfeng, the head of the epidemiological investigation team. But workers and doctors at the hospital declined to confirm that status, and Shanxi's anti-SARS office refused to disclose names of such patients.

A lot is riding on the diagnosis. Under a new policy, if a patient is confirmed with SARS, medical treatment is free. "We will not allow hospitals to ask farmers to take money out of their own pockets," said Agricultural Vice Minister Mr. Liu. But government departments have offered conflicting views on who foots the bill for those merely suspected of having SARS. A Ministry of Health official in the Office for SARS Prevention and Treatment has advised hospitals to keep track of expenses, so patients who don't have SARS can be billed later.

Dodging the diagnosis can be a double-edged sword, says Mr. Bekedam of the WHO. "OK, you are lucky -- you don't have SARS," he says. "But then you are unlucky, because you have to pay."

Mr. Liu's illness has already cost his family. His mother says her employer, a department store in Qingxu county, fired her as a cleaner because her son was a suspected SARS patient. "Now, I dare not even go outdoors," she said in a telephone interview. "Villagers are scared."

Just north of Mr. Liu's home, another village, Beiying, with about 2,000 residents, is sandwiched between outbreaks in Shanxi's capital of Taiyuan and Qingxu city. It is fighting the SARS war, armed with a typically fragile health infrastructure.

In fact, Wang Zhengyou is the health infrastructure. As the village's only doctor, the 50-year-old is more accustomed to treating farmers who have inhaled too much pesticide. On normal days, he stands behind a glass counter like a proud shopkeeper, doling out packets of Chinese and western medicine. His tiny two-room clinic, with peeling lime-green paint, is down a winding dirt road. The village recently put up a barricade of weeping-willow branches, to keep outsiders away. Though Dr. Wang knows of SARS cases in nearby villages, he hasn't treated any yet.

"I have your medicine," he tells an old farmer who comes into his clinic holding out bulbous arthritic hands. The price he charges for two packets of brown pills is less than 40 cents -- Mr. Wang says he sticks to a government-allowed margin of profit -- but the money still must come out of the patient's own pocket.

Mr. Wang once counted himself among Mao's "barefoot doctors." A former farmer, he did a three-year internship at local hospitals and clinics before becoming the village doctor 32 years ago. He has seen big changes since then. In 1973, he recalls taking a truck driver with a burst appendix to the county hospital -- where six doctors successfully operated on the man for free. With money for immunizations, the village steered clear of a measles epidemic about 30 years ago, without a single death, he says. Beiying hasn't had a serious problem with measles since, he says, although today farmers must pay about 50 cents for measles vaccinations.

Scholars point out that Mao's radical policies unleashed famine and disease, killing millions. Still, life expectancy in China rose from less than 40 years in 1950 to 69 years in 1982. Two decades later, the average has increased by just one year to 70.

With recent economic reforms, Dr. Wang has also become a businessman. He passed an exam and received a license to sell medicine for profit. As a result, like many others in the last 20 years, he has seen his income rise. "We shouldn't forget that it was Mao Zedong who liberated us, but we relied on Deng Xiaoping for wealth," the doctor says.

Many around here aren't seeing wealth, only prohibitive medical costs. One is Wang Shangfu, tending a herd of a hundred sheep outside Beiying. Under Mao, the shepherd never worried about getting sick. Now, as SARS cases encircle his village, he worries his family doesn't have the means to go to hospitals. He flicks a clod of dirt with his hoe, driving back a wayward member of the herd. "Could things get any worse?" Mr. Wang asks.

Chinese authorities are trying several ways to prevent the further spread of SARS in rural areas. Some migrant workers are being quarantined, so they can't return to their home villages. In places such as Ming Li village, near a SARS-infected city in Shanxi, the health threat has prompted the reimposition of Communist Party controls.

Red poster paper in Communist party headquarters detail duties for over 100 people in the campaign to keep Ming Li free of SARS. Entrances to the village are roped off; four village doctors patrol the neighborhood; and residents coming and going are monitored. "We know who our guests are," says Ming Li's raspy-voiced deputy Communist party chief, Yan Maogui. "And if residents are leaving, we know where they are going, too."

The Taiyuan city government, like others in China, is even offering a reward for successfully reported SARS patients. The bounty: 500 yuan, or $60 dollars each, at least a month's wages in these parts.

In this environment, Beiying village's only doctor has begun to moonlight as a fever hunter. Dr. Wang recently bought a new medical bag, black and emblazoned with a red cross. He stuffed it with a bright white lab jacket, a surgical mask and a 12-pack of disposable thermometers. Villagers say he roams day and night in search of those with SARS symptoms. He also works with other doctors in the area, stopping cars at a 24-hour roadblock outside his village. He's only found a few feverish people, he says, and no SARS patients.

"He's a good doctor," says a 74-year-old man standing guard beside the barricade of willow branches.

"The situation is very tense," Dr. Wang says. "But if we rely on scientific methods and government measures, we can beat this."

[Under Siege]