The Demise of the Barefoot Doctors &
the Health Crisis in China's Countryside

Revolutionary Worker #1096, March 25, 2001, posted at

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.

From The New York Times (3/14/01)

Zhang Youlian has no medical insurance or welfare benefits to cover the costs of health care. So she was forced to borrow money from family members. Now she doesn't know how she'll pay it back.

This is the plight of many of China's 800 million people who live in the countryside.

According to a recent United Nations report, health costs in China have increased 400 to 500 percent from 1990 to 1997. And medical care in the rural areas is so expensive that most people have had to stop seeing doctors, except for extreme emergencies. Because of this, people end up suffering from all kinds of chronic pain, infections, and treatable diseases. Illness is now a major factor contributing to families falling below the poverty line.

When China was a socialist country under the leadership of Mao Tsetung, it had a whole system of "barefoot doctors" and free clinics that provided medical care in the rural areas. But in 1976, after Mao died, a reactionary coup took place and capitalism was brought back. All the tremendous gains that had been achieved under socialism--including a health care system devoted, not to making profits, but to "serving the people"--were reversed. And as a direct result, hundreds of millions of people in China today don't have any adequate health care.

Under socialism, centralized planning included the allocation of subsidies for social services like education and health care. But today, as more and more things in capitalist China have become privatized, such much-needed, affordable services have disappeared. And the situation is especially dire in the countryside, where most of the people in China live.

The rural health system has become a mixture of hospitals and clinics that are often privately run and almost always too expensive for people to afford. A farmer might have to spend two months income to get treatment for a cold. A woman who wants to give birth in a hospital has to come up with two years of hard-earned cash.

Revolutionary China

"If you are really sick, you borrow and go to the doctor. 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 [$15]."

Woman in China's countryside,
quoted in The New York Times

Like this woman, many people in China remember what it was like under socialism (and in the few years after 1976 when some socialist things had not yet been dismantled). They have seen the system of mass health care developed under socialism, dismantled, step-by-step. They have seen the return of widespread cases of tuberculosis--which had been brought under control. And they have seen the disappearance of the "barefoot doctors."

Barefoot doctors were one of the "socialist new things'' created during the Cultural Revolution (see sidebar). These young revolutionaries were sent out to the countryside where there had been little or no health care. They were picked to receive medical training not because of their grades or their family's wealth, but because of their dedication to serving the people.

They were called "barefoot doctors'' because they continued to live and work among the common people, including working barefoot in the fields.

The barefoot doctors were trained using a Maoist approach to education: simplified and concentrated training combined with "learning warfare through warfare.'' There was an urgent need for health care in the rural areas and in this way, barefoot doctors could be trained fairly quickly to be able to deliver basic medical care and education.

After five years of the Cultural Revolution there were about 1.8 million barefoot doctors, along with another 2.4 million public health workers and midwives. They were able to take care of about 80 percent of the medical needs of the masses of people--very often in areas where there had never been medical care before.

Many of these barefoot doctors were young women who, along with men, distributed birth control, performed simple and safe abortions, provided pre-natal care and assisted in the delivery of babies.

Diseases of the Free Market

"In some provinces, there is no system left, and it's every man for himself."

A health expert who works at a
state research institute in China

Today there are no more barefoot doctors in China. Many of the clinics that were set up under socialism still exist--according to an official in the Rural Health Division in the Health Ministry, almost 90 percent of the villages have at least one clinic. But government subsidies for these clinics are gone. And even the state-owned clinics that are still around are often contracted out.

With the return of capitalism, many areas simply cut loose clinics and hospitals that used to be run by the government. Most of these facilities are now privately owned. Running on a "for profit" basis, they set their own rates, which are too expensive for many, if not most people.

This has created a situation where hundreds of millions of people in China's countryside go without basic health care. And current health statistics reflect the consequences of this situation:

The number of tuberculosis cases has quadrupled in 15 years.

Infant mortality, which had been declining steadily for most of 40 years, is beginning to creep up in poor areas.

Immunization rates in the countryside, which used to be high, have now declined.

In poor areas like the Shanxi and Guizhou provinces, the treatment of measles is as low as in many sub-Saharan African countries.

In socialist China, doctors and medicine became widely available and great efforts were made to close the gap between rural and urban areas and between those of different incomes. Even the World Bank (one of the major global imperialist financial institutions) admits that under Mao, China had the most egalitarian health care system in the world. But today it ranks towards the bottom in terms of equality, along with the United States.

The Chinese government still limits doctors' consultation fees to 60 cents a visit, a sum that has not changed for decades despite inflation. This is another thing left over from the time when socialist China provided mass, affordable health care. But today, this regulated low-cost of a clinic visit, is added on to all kinds of other costs which people can't afford. For instance, there is little regulation of charges for medicines, injections and tests, which are prescribed in abundance.

Widespread immunization was another thing accomplished under socialism. And today, a basic immunization set is still technically free. But patients often have to pay all kinds of added costs--like "administration fees" and payment for needles and syringes. And 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 widespread in China.

A simple hospital stay could cost more than a year's income for most peasants. So many, if not most of the women in the countryside risk childbirth at home. Many times this means giving birth without prenatal care, in unheated houses with no running water. Some cannot get medical care because they are hours away from a hospital. But even for those who live near a hospital, the problem is money.

This has led to high rates of infant mortality and women's deaths in childbirth. The New York Times reported that in one county, children died before their fifth birthday at a rate of 64.7 per 1,000, twice China's national average. And 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.

A recent United Nations report estimates that only 29% of women in poor counties in China can afford prenatal examinations and that only 6% can afford hospital deliveries.

Health researchers in China told The New York Times that "the new market-driven care offers few advantages to hundreds of millions of rural poor, the new setup fails at tasks that the old system [i.e. the one developed under socialism] performed so well like public health campaigns and immunization drives." Today, clinics are not going to trek out to distant villages to vaccinate children or provide prenatal care because it's just not profitable.

China's capitalist rulers boast of modernization and engagement with the world market. But the restoration of capitalism--and the savage consequences it has had on people--shows an important truth: that socialist revolution is decisive in order to develop a health care system that really serves the people.

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