Chinese peasants encouraged to heal themselves

More striking is the regard for basic health and hygiene: smoking and spitting are commonplace, even among the doctors

Teresa Poole in Guanyindang, Hubei province, sees the effects of health cuts

Wan Liangmo, his head swathed in a grubby bandage and his arm connected to a saline drip, was not short of company as his wife described how he had ended up in Guanyindang township sub-hospital. Sitting on his bed or lolling around were half a dozen peasants, smoking and sometimes spitting on the dirty concrete floor.

Four days earlier Mr Wan's tractor had collided with a truck overloaded with straw and the drivers came to blows. The big question now was who would pay for Mr Wan's treatment. His wife said with some feeling: "It's difficult for us to pay." An irritated Mr Wan roused himself from his pillow to insist that there was no question the money would have to come from the other driver.

Before China's economic reforms in the early 1980s, medical care for rural farmers like Mr Wan was even more primitive - but at least it was free. These days the country's 900 million peasants get what they pay for. Government funding for rural health care has virtually collapsed, leaving patients to foot the bills. At the Guanyindang sub-hospital in 1994, patients' fees amounted to 1.12m yuan (£86,000) out of the annual budget of 1.36m yuan (£105,000).

Only children under seven, very poor farmers and old people received free services, said the hospital's director, Wang Yifa. Even in a relatively well-off area like Guanyindang, in central Hubei province, patients can be hard-pressed to afford medical care. According to Dr Wang, an appendix operation would probably cost 600 yuan (£46), "including bed and medicine and food, operation, electricity and water". Surgery to "take part of the stomach out" could be performed for less than 1,000 yuan.

This compares with an average monthly income in the township of about 1,200 yuan (£92).

In the cities it is different. Almost all urban employees are still provided with virtually free health care through their work- units. In the countryside, the disbanding of the commune system in the early 1980s raised living standards but also undermined the existing social-welfare structures.

"Because of the deterioration of most of the rural medical services, 80 per cent of the total population could be denied timely basic health service," said a recent article in the official Outlook magazine. Guanyindang sub-hospital serves a population of 46,000 but only nine of its 50 in- patient beds are occupied. This may be because the local farmers are extraordinarily healthy but more likely it is because many cannot afford to come for anything other than childbirth or accidents.

In this area, as elsewhere in rural China, when a farmer gets sick, his first port of call is the village "health-room", or clinic, usually staffed by two or three "countryside doctors" with only rudimentary training. If the problem cannot be solved, the patient moves on to a township sub- hospital, like the one in Guanyindang, and if he cannot find help there, he is referred to the district hospital. In Jiangling district, of which Guanyindang is part, there is one university-trained doctor for every 6,800 people.

At the village level there are sometimes co-operative health- care schemes to which the village collective and the individual farmers all contribute. "We encourage all farmers to join a co-operative health scheme," said Zhu Rong, director of Jiangling health bureau. The system is far from widespread, however. Otherwise, the only health cover is through the state insurance company but this is even rarer. Standards have improved with 15 years of economic growth in China but the basic level of treatment available to the majority of the population is still dire.

The present Guanyindang sub-hospital building is less than five years old but it already has broken windows, does not get cleaned and has draughty, unheated rooms that add to the atmosphere of neglect. More striking still is the disregard for basic health and hygiene: smoking and spitting are commonplace, even among the doctors, and the outdoor lavatories gape over open sewers.

Sitting in the reception-room with the hospital's senior staff, the question of qualifications naturally arose. What was the medical training of the hospital's director, Mr Wang? "No formal training," he said. And his deputy, Zhang Debing? "No formal training."

The chief specialist, Xu Daogong, trained at Chongqing Medical Science College for three years but only three others out of 79 "medical personnel" are fully trained doctors.