Barefoot Doctors Make a Comeback In Rural China
Trained as a Nurse, Ms. Li
Treats Datang Village;
Delivering a Baby for $4
DATANG VILLAGE, China -- Shortly after Li Chunyan married five years ago, she sold her wedding gifts -- two water buffaloes -- and set up a tiny medical clinic next door to a pigpen. Her only competition in this hamlet with no running water was a witch doctor who treats patients by chanting and ringing bells.
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 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."
中国农村依然需要“赤脚医生”
五年前，李春燕新婚不久就卖掉了婆家赠送的财礼──两头水牛，在贫困的大塘村开设了一家小小的卫生室。她唯一的竞争对手是一位诬师，此人靠跳大神儿“治病”。
乡亲们已经开始习惯于有病到她这里打针吃药。作为一名护士学校的毕业生，今年28岁的李春燕已经是附近教育程度最高的医生了。
多数日子里，李春燕主要忙于治疗感冒和发烧。有时候也要翻过长满水稻和卷心菜的梯田，到就医更不方便的临近村庄为产妇接生。“现在连诬师都要到我这来看病了，他总是流鼻涕，”头发利落地束在脑后的李春燕骄傲地说。
在中国西南部贵州省的这块边远地区，李春燕是重新涌现的“赤脚医生”之一，“赤脚医生”的出现也是毛泽东在六七十年的一项重要功绩。所谓赤脚医生是指那些在边远地区为降低婴儿死亡率和根除传染疾病作出重要贡献的农村医务工作者。当地政府会选出赤脚医生的培养对象，然后对这些人进行三到六个月的培训，使他们掌握一些卫生知识，可以治疗常见病，并能为产妇接生。这个名称也是对最底层医护人员的一种形象描述，他们当中很多人还要继续耕地种田，常常赤著脚在农田里干活。
眼下，随著中国边远地区的医疗体系逐渐衰落，全球流行疾病的威胁日益严重，赤脚医生这一毛泽东时代的产物又有了用武之地。
但现实情况却要困难得多。尽管中央和地方政府都发出了补充更多赤脚医生的倡议，但像李春燕这样的人仍然寥寥无几。从江县地方政府一直希望他们的360个村子里都能有赤脚医生，但却无力负担这笔费用，所以也一直未能实现目标。赤脚医生无法从国家获得补贴，而普通的乡村医生每月则可以领到100美元左右的工资。
结果，多数赤脚医生和周围的邻居一样生活困苦。2000年与李春燕一道毕业于这个世界银行(World Bank)资助项目的25名同学中，只有一小部分仍然留在医疗领域。他们大多数选择了到薪水较高的城里打工。李春燕有时甚至不得不接受患者的鸡、鸭、蛋来代替现金。她翻山越岭几小时到其他村子为产妇接生，但最多只能挣到4美元，有时获得的报酬只有区区6美分。
李春燕的部分医疗技能来自于毛泽东时代的一位赤脚医生──她的父亲李汉明。1965年，李汉明中学毕业后接受了6个月的培训，之后就开始在乡村公社给人看病。如今，由于对中、西医都有了解，来找他的患者仍然络绎不绝。这位61岁的老先生每周都要去山里采药，弄些灌木、草根回来，用于治疗感冒、咽喉肿痛和痢疾。
毛主席倡导下的赤脚医生帮助实现了中国翻天覆地的变化。得益于六十年代开始推行的疫苗接踵项目，中国成为了率先根除天花和小儿麻痹症等高度传染疾病的发展中国家之一。到七十年代，中国在减少婴儿死亡率方面已经领先于马来西亚和印尼等其他发展中国家。当时，中国农村居民中有85%可以接受公社资助的医疗。
然而在中国向市场经济转变的过程中，很多这样的成就遭到了遗弃。部分原因可能在于中国政府取缔了公社，而公社正是资助医疗的重要部门，此外，政府还停止向赤脚医生支付工资。很多赤脚医生被迫回家种田。其他人则开起了药店，依靠高价售药来维持生计。
进入九十年代，医疗成本迅猛增长，而农村收入却难以跟上。对医疗成本的担忧已成为很多中国人紧衣缩食的重要原因；人们在看病前必须预交押金，很多人只能靠向亲戚朋友借钱治病。在世界卫生组织(World Health Organization)最近对190个国家进行的医疗卫生公平性评价中，中国被排到了倒数第四位。
3月份，中国国务院下属研究机构以罕见的犀利言辞发表了一份报告，称几十年的医疗改革“不成功”。国务院总理温家宝上个月承诺，将在农村推行医疗救助制度。
海外健康专家表示，中国医疗改革失败的风险很高──而一旦失败受害的不仅仅是中国。如果这个世界人口第一大国的很多地区不能得到最基本的医疗保障，像非典型肺炎(SRAS)、艾滋病(AIDS)、禽流感这类疾病将很容易在全球蔓延。
李春燕这样的人正是解决这些问题的重要力量。北京大学(Peking University)中国经济研究中心提出建议称，政府应该像过去那样鼓励赤脚医生的存在。他们应该接受免费培训，并享有政府提供的工资，应由他们来充当健康教育和疾病预防的排头兵。
但批评人士指出，这种提议太不切实际了。“乡村医生和赤脚医生们已经基本上成了药贩子，”哈佛大学(Harvard University)公共健康学院教授William C. Hsiao说。他正在牵头实施改善中国农村地区医疗状况的一个试验项目。
Hsiao表示，医生技能不高并不是中国医疗问题的关键所在。在今天的市场经济社会，中国农民真正需要的是获得可以负担的医疗保险，让医生的行为受到村委会的监督。
李春燕居住的大塘村距离繁华的上海有1,900多公里，这里很多农民甚至无力支付最低水平的医疗保险。多数家庭一年的收入不足60美元，远远低于中国的贫困线。这一带是少数民族苗族的聚居区。妇女穿著黑色的束腰外衣，经常干著扛水打柴的活儿。男子头上包著小包头，还在用烟袋吸著自家种植的烟草。
李春燕来到这里主要因为她爱上了当地的小伙子、苗族青年孟凡兵，孟凡兵也是她的中学同学。中学毕业后，李春燕继续去卫校学习，孟凡兵则因为家里无力承担进一步深造的学费而应征入伍。
两人结婚时，李春燕的婆家送给他们唯一的财礼就是两头水牛。李春燕很快以250美元，也是远远低于市价的价格将它们卖掉，用这部分钱在他们房子的角落里开了她的卫生室。
患者可以在他们需要治疗的时候随时前来。一天晚上10点45分左右，李春燕夫妇刚刚吃完饭，正在收拾碗筷，一位妇女就进来了。迅速询问过病情后，李春燕开始用剪刀捅开封著的玻璃瓶，给那位妇女怀里流著鼻涕的2岁小孩注射抗生素，并辅之以传统中药，以缓解他的烧热。这位妇女付给李春燕两张一块钱的纸币，合25美分。她只收了一张。
第二天一早雄鸡刚刚报晓，她的第一批患者就来了──另外两个患了感冒的小孩。他们也注射了同样的抗生素，外加一些含蛇胆成分的止咳药。
专家已经对中国边远地区医生过度依赖抗生素的做法提出了批评。李春燕说，她这样做是为了防止疾病迅速扩散。
唯一一位在李春燕诊所里住院的患者是吴劳弄（音），她5月份为了在生产之后止住流血曾经看了一位诬师。他们家为躯赶邪气花了35美分，然而这个女人却很快陷入了昏迷。一周后，他们家卖掉了牲畜，从朋友那借了1,700美元把她送进了县医院。李春燕又从自己的积蓄中拿出了另外360美元以保证她能继续住院。
一周后吴恢复神志时，不能讲话也不能走路。随后她转到了李春燕的卫生所，每天注射葡萄糖、维生素C和一种中药制剂。现在，这位27岁的苗族女人已经能够短距离地散步，低声地提醒她丈夫去喂小孩，李春燕的儿子把唇膏涂到自己腿上时她还会咯咯地笑起来。为了回报李春燕的治疗，吴的爸爸和哥哥正在参加诊所的扩建工作。
李春燕现在的最大愿望就是建一个新诊所。很多人在当地报纸上看到她的事迹后已经给予她很多捐助，使新诊所得以破土动工，然而由于资金不到位，小楼完成一半就停工了。还有另外一个令人沮丧的消息：村里一个原本有意在这个诊所做学员的小女孩改变了主意。“我是这个村子的第一个赤脚医生，”李春燕骄傲地说。“我希望我不是最后一个。”
