January 14, 2006 – Copyright The New York Times
By HOWARD W. FRENCH
FUYANG, China – When Jin Guilian’s family took him to a county hospital in this gritty industrial city after a jarring two-day bus ride during which he drifted in and out of consciousness, the doctors took one look at him and said: “How dare you do this to him? This man could die at any moment.”
The doctors’ next question, though, was about money. How much would the patient’s family of peasants and migrant workers be able to pay – up front – to care for Mr. Jin’s failing heart and a festering arm that had turned black?
The relatives scraped together enough money for four days in the hospital. But when Mr. Jin, 36, failed to improve, they were forced to move him to an unheated and scantily equipped clinic on the outskirts of Fuyang where stray dogs wandered the grimy, unlighted halls.
China’s economic reforms have turned an almost uniformly poor nation into an increasingly prosperous one in the space of a mere generation. But the collapse of socialized medicine and staggering cost increases have opened a yawning gap between health care in the cities and the rural areas, where the former system of free clinics has disintegrated.
In the last several years China has experimented with reforms aimed at improving health care for peasants. The most important is an insurance plan in which participating farmers must make an annual payment of a little more than a dollar to gain eligibility for basic medical treatments.
Many peasants have complained that even the dollar payment is too big a burden and that in any event the coverage the plan theoretically provides is inadequate.
The government, which under President Hu Jintao has made rural living standards a top priority, has recently announced an expansion of this experiment, with increased fees and increased coverage, but it has yet to make an impact on the health crisis.
As a result, according to the government’s own estimates, in less than a generation a rural population that once enjoyed universal, if rudimentary, coverage is now 79 percent uninsured.
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 like severe acute respiratory syndrome, or SARS, and possibly bird flu.
The failure of the government to provide decent health care for peasants has reinforced the idea of China as two separate nations: one urban and increasingly comfortable, the other rural and increasingly miserable.
Every year hundreds of millions of rural Chinese, like the Jin family, face the clash between health and poverty, knowing that if they treat their illnesses they will lack the money needed for marriage, education and, sometimes, food.
Even the official Chinese news media are regularly filled with accounts of the desperate choices people are forced to make over health care, of brothers who must draw lots to see whose serious disease will be treated because their family cannot afford to treat both, or of a father who sells a kidney to treat an ill son.
“There’s basically no safety net at all for medical care in the village I live in,” said Yang Yunbiao, a worker with a Chinese independent organization in Fuyang that aids poor sick people. “Our village has a lot of aged people with disease who are unable to get treatment, just staying at home in bed with barely enough to eat. They are shut in and can’t work, and their disease and poverty have taken away their dignity.”
In Mr. Jin’s case, the best doctors could do was to administer oxygen and an antibiotic drip. But the new locale did have one sure merit: with their savings nearly exhausted, of all the places the Jin family had taken their brother in a 500-mile trek from Guangdong Province, it was the cheapest, costing what for them was still an exorbitant fee of about $15 a day.
“We don’t want to go anywhere else,” said Jin Guibin, an elder brother who spoke at the patient’s bedside in his frigid room. “If he dies, he’ll die here. If he recovers, he’ll recover here. We don’t have any other means.”
That China finds itself in this situation today is as remarkable as the country’s economic takeoff and, paradoxically, is inseparably related to it. Until the beginning of the reform period in the early 1980’s, China’s socialized medical system, with “barefoot doctors” at its core, worked public health wonders.
From 1952 to 1982 infant mortality fell from 200 per 1,000 live births to 34, and life expectancy increased from about 35 years to 68, according to a recent study published by The New England Journal of Medicine.
Since then, in one of the great policy reversals of modern times, China has dissolved its rural communes, privatized vast swaths of the economy and shifted public health resources away from rural areas and toward the cities. Public hospitals were urged to charge commercial rates for new drugs and most procedures, and today the salaries of health care workers are typically linked to the amount of income they generate for their hospitals.
More than half of urban residents, by comparison, enjoy some kind of coverage, which is supplied by their employers.
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.
“Maybe it is the beginning of something simple that if taken care of in time wouldn’t be a problem,” Mr. He said. “But these people are too poor to pay even five yuan or two yuan.”
The story of Jin Guilian, the migrant worker with heart problems who was taken home to Anhui Province by his family from Guangdong, 500 miles to the south, displays all of those weaknesses in the public health system and more.
Seeking employment, Mr. Jin set out from his village in Anhui, one of eastern China’s poorest provinces, when he was in his early 20’s. Living with an uncle in Heilongjiang Province in the far northeast, he collapsed one day while hauling wood. He was taken to a hospital but left without treatment for lack of financial means.
That was the first of several incidents pointing to what doctors eventually diagnosed as congenital heart disease, a condition that has gone untreated. Some doctors have urged his brothers to arrange valve surgery, which they say would cost about $10,000, in a big city like Shanghai.
Ever desperate for work, Mr. Jin later made his way to Shantou, a city in Guangdong, not far from Hong Kong. There he got a job working as an orderly in a large hospital for about $6 a day. From those meager earnings, about $30 a month had to be paid to the hospital for the privilege of holding the job.
It was at the Shantou hospital that Mr. Jin recently fell gravely ill. But as “just a migrant laborer,” he said from his bed in the Fuyang clinic, he was denied treatment by his employer of 10 years. “Although I worked there, I knew that I’d have to pay a deposit to get treated,” he said. Unable to afford that, he left the hospital for a neighborhood clinic, where he was put on a simple saline drip.
He summoned his family, and when they saw him, visibly weak and with his blackened arm, they decided that his chances would be better if he returned home. Asked whether he regretted not having his brother treated earlier, Jin Guixiu, another brother of the patient, grew emotional.
“How can I not regret, but what good would that do?” he said. “For villagers the problem is not enough money. This is my brother, and if I had enough money of course I would treat him.”
* Copyright 2006The New York Times Company
January 14, 2006 – Copyright The New York Times