EAST LAKE VILLAGE, China — Just as he did as a "barefoot doctor" 30 years ago, Fang Zhengchun still makes house calls wearing the straw hat of a Chinese farmer, a small medicine box strapped over his shoulder.
But while Fang's routine is the same, the system of grass-roots medicine that once made China a world leader in rural health care has changed. Under market reforms, free clinics are out and medical care has to be paid for, putting it beyond the reach of hundreds of millions of Chinese living in or near poverty.
Before the Communists took power in 1949, revolutionary leader Mao Tse-tung was writing poems urging poor farmers to struggle on even when parasitic diseases sapped their strength. The average life expectancy was 35. Early childhood was perilous.
Communist China's new leaders made health care a priority. Life expectancy rose--to 68 for men and 72 for women today. Infant mortality rates dropped, from 200 per 1,000 births to 32 per 1,000.
But these gains are in danger of being reversed in rural areas. The reformist national government has shifted responsibility for health care to cash-strapped local governments. In poor areas, these township officials often find little to spend on health.
Clinics are expected to make profits, particularly from drugs and high-tech tests. The government pays only about 70% of doctors' modest salaries, leaving them to make up the rest mostly by charging a 15% markup on medicines.
Infant mortality rates in some poor areas have gone up to 72 per 1,000, according to a study by Harvard School of Public Health researchers and Chinese colleagues. Another international study found higher figures--nearly 100 per 1,000 in some remote western areas--on a par with rates in the world's least developed countries.
A stay at a county hospital can cost poor farmers more than their annual disposable incomes. A study said the average cost of delivering a baby in a hospital in four poor provinces was more than 400 yuan ($50), or more than two-thirds the annual income of a family at the poverty line.
"When poor farmers who absolutely can't afford to see a doctor get sick, all they can do is lie in bed," reported the Farmers Daily. "If they get something serious, they suffer and weaken until they see the King of Hell."
Doctors are so poorly qualified in some places that clinics would find even a health worker with a middle school education a treasure, the newspaper said. It added that, in some regions, village clinics are few and far between and area hospitals are shabby.
In the 1960s, China trained more than 1 million "barefoot doctors" to take health care to the poor. They worked full-time at clinics in rural communes, taking charge of inoculation campaigns and treating minor illnesses.
Although the folksy term has been dropped under economic reforms, part-time village doctors, usually middle school graduates with about six months of medical training, still work the countryside.
"Now the job is a lot easier because vaccinations have eliminated so many diseases, like measles," said Fang, who became a barefoot doctor in 1968 during a shortage of health care workers.
Fang's East Lake Village is a prosperous region in southern China's Jiangxi province, an area of fertile rice and vegetable fields dotted with duck ponds.
His clinic is a room in his house equipped with little more than an old bamboo cot, a desk and a wooden cupboard full of pain and cold medicines. There is no telephone, but Fang, a part-time farmer, said he is never far from home.
Doctors like Fang began collecting fees after the breakup of the communes, when land was turned over to families in the early 1980s.
Fang remembers when poor villagers had to borrow to pay him, but says no one is that poor anymore. Most of East Lake Village has joined a new voluntary prepayment plan in which they pool funds to cover visits to Fang and part of any hospitalization costs.
Experts say the prepayment plans, which cover less than half the rural population, are no solution in remote areas, where there are too few people with too little money to put enough together to pay for decent care.
In a remote part of Guangxi province in southern China, several members of the Nobel Prize-winning Doctors Without Borders humanitarian group train village doctors and work with local officials seeking a better way to finance medical care.
There is no incentive for village doctors to give vaccinations, said Dr. Marc Postel, a French physician in the group. On the contrary, picking up the vaccines from the nearest township clinic may mean a five-hour walk over steep hills in the rain.
The government has allocated $12 million to upgrade medical clinics and obstetrical care in poor areas to improve women's and children's health.
Western experts say one problem with this initiative and the fund-pooling system is supervision to prevent abuse.
Cai Renhua, director of the China Health Economics Institute under the Ministry of Health, has called for reform to stop unnecessary use of expensive medicines. But he argues it is wrong to conclude China's entire health system has declined. Commune clinics were too poor and inefficient, he says.
Cai says the government has improved rural clinics in the last decade, but still needs to do more for poor areas. He argues the main need is for better-trained rural doctors and incentives to get urban doctors to do stints in rural areas.
"We're trying to find a way to have a good horse--but one that doesn't eat much grass," he said. "It's impossible."