Wall Street Journal - September 22, 2005
Peter Wonacott, peter.wonacott@wsj.com

Villagers have opted for Ms. Li's conventional cures. As a graduate of a three-year nursing-school program, the 28-year-old is by far the best-trained healer in these parts.

On most days, she's busy treating colds and fevers. When called, she climbs terraced hills of rice and cabbage to deliver babies in villages that have no doctor. "Even the witch doctor comes to see me now," boasts Ms. Li, a petite woman who keeps her hair pulled back in a neat knot. "He gets the sniffles."

In this remote corner of China's southwest Guizhou province, Ms. Li is helping revive one of Mao Zedong's storied successes of the 1960s and '70s: the "barefoot doctors," countryside medics who did a lot to reduce infant mortality and eradicate contagious diseases. Local authorities singled out candidates, who continued to work as farmers and didn't wear shoes in the fields. In three to six months of training, they learned to promote hygiene, treat basic ailments and deliver babies.

Now, amid a collapse of health care in China's countryside, and looming threats of global pandemics, this vestige of communism is making a comeback.

Despite a push to recruit more barefoot doctors, Ms. Li is still a rarity. Local authorities in her county of Congjiang want doctors for each of their 360 villages, but they can't pay them and haven't met that goal. Barefoot doctors don't get subsidies from the state, compared with village doctors who are paid a small salary of about $100 a month.

As a result, most barefoot doctors are as poor as their neighbors. Among Ms. Li's 25 classmates graduating in 2000, in a program funded by the World Bank, only a few stayed in the field of health. Most quit for jobs in the cities that paid better. Ms. Li accepts IOUs as payment from her patients, also, chickens, ducks and eggs. She has walked hours to other villages to deliver babies for as much as four dollars and as little as six cents.

Part of her training came from one of Mao's original barefoot doctors: her father, Li Hanming. In 1965, Mr. Li, a middle-school graduate, got six months' training before he began to treat patients at the village commune. Today, locals seek him out for his knowledge of Western and traditional Chinese medicine. Once a week, the 61-year-old scours the sides of mountains for shrubs and roots to treat colds, sore throats and diarrhea.

Mao's barefoot doctors helped change China. Thanks to vaccination programs begun in the 1960s, China was among the first developing countries to eradicate highly infectious diseases like smallpox and polio. By the 1970s, China had outstripped other developing countries, including Malaysia and Indonesia, in reducing infant mortality. At the time, about 85% of China's rural residents had access to community-financed health care.

But in China's shift to a market economy, many of these achievements have come undone. That's partly because Beijing dismantled the communes, which heavily subsidized health care, and stopped paying barefoot doctors. Many returned to the fields. Others opened shops and relied on selling medicines at inflated prices to stay in business.

Through the 1990s, health-care costs soared, while rural incomes did not. Fears of health costs are among the main reasons the Chinese save so much money; people are expected to pay in cash before treatment, and many must resort to borrowing from families and friends. The World Health Organization recently ranked China fourth worst among 190 countries for equality of health care. [Li Chunyan prepares an injection] Li Chunyan prepares an injection in her countryside clinic. A young neighbor assists by holding the baby down.

In March, a think tank under China's State Council, or cabinet, issued a rare scathing report on health care, judging decades of reform "unsuccessful." Last month, Chinese Premier Wen Jiabao pledged to extend subsidized health care to rural residents.

Foreign health experts believe the risks of China's health failures are high -- and not just for China. If swaths of the world's most populous nation lack rudimentary health care, diseases such as SARS, AIDS, or flu outbreaks originating from birds and pigs, will have an easier time spreading globally.

Ms. Li is part of efforts to remedy these problems. Under one proposal from the China Economy Research Center at Peking University, barefoot doctors would be encouraged by the government as they were in the old days. They would receive free training and government-paid salaries, and they would spearhead health education and vaccinations.

Critics say such proposals are too romantic. Village and barefoot doctors "have essentially become drug peddlers," says William C. Hsiao, a professor at Harvard University's School of Public Health. He is leading a project to improve health-care coverage in China's rural areas. Mr. Hsiao says semitrained medics aren't the answer. What China's farmers really need in today's market economy is affordable insurance and doctors whose services are monitored by an elected village committee, he says.

Where Ms. Li works, about 1,200 miles from wealthy Shanghai, many farmers can't even afford a minimum level of health insurance. Most families earn less than $60 a year, well below China's poverty line. A Chinese ethnic minority, known as the Miao, populates nearby villages. Women dress in black tunics and carry sloshing water buckets up dirt paths. Older men stash wads of homegrown tobacco in checkered head kerchiefs and smoke from skinny wood pipes.

Ms. Li went to Datang because she fell in love with a local boy, Meng Fanbin, an ethnic Miao who was her middle-school classmate. After they graduated, Ms. Li went on to nursing school. Mr. Meng enlisted in the army because his parents couldn't pay for more education.

When the two married, Ms. Li's in-laws gave them the two giant water buffaloes. Ms. Li promptly sold both for $250, well below the market price. With the cash, she built her clinic in a corner of their house.

Patients simply arrive at her doorstep when they need care. At 10:45 one recent evening, a woman lingered in the shadows as the family cleared away dishes from dinner of beef and red chili peppers. After quick conversation, Ms. Li used scissors to break sealed glass vials. She gave a runny-nosed 2-year-old an injection of antibiotics and a traditional Chinese medicine to relieve his fever. The woman offered two yuan bills, or 25 cents. Ms. Li took only one.

The next morning, roosters were crowing when her first patients arrived -- another two children with colds. They got the same injections, plus some cough syrup made from snake bile.

Experts have criticized the overreliance on antibiotics among doctors to treat patients in the Chinese countryside. But Ms. Li says her strategy is to stem sickness before it spreads.

The only patient staying in the clinic was Wu Laonong, who had turned to a witch doctor in May to try to stop the bleeding after the birth of her son. The family paid 35 cents to drive away evil spirits, but the woman soon slipped into a coma. A week later, the family had sold livestock, borrowed from friends and raised $1,700 to admit her to the county hospital. Ms. Li chipped in an additional $360 from her savings to keep her there.

After Ms. Wu regained consciousness several weeks later, she couldn't speak or walk. So she checked into Ms. Li's clinic and began to receive daily doses of glucose, vitamin C and Chinese herbs through an intravenous drip. Now the 27-year-old Miao woman groans out orders to her husband to feed the baby and laughs when Ms. Li's son spreads lipstick on his leg. Above the clinic, the woman's father and brother are building a new addition to help repay Ms. Li for her care.

Ms. Li wants to build a new clinic. Donors who read about her work in a local Chinese newspaper contributed enough to start, but the structure remains a half-completed brick husk. Another setback: a young village girl who had expressed great interest in an apprenticeship stopped coming around. "I am the first barefoot doctor in this village," Ms. Li says proudly. "I hope I'm not the last."

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