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Fight for a healthy state of mind

By: Medecins Sans Frontieres overcame official distrust and patients' fears to bring health care to a rural area. Jasper Becker reports.

October 19, 1999

The recently restored hospital in Gongdong should be busy: it serves a population of 110,000 Miao, Dong and other minorities in Rongshui county, Guangxi, where three-quarters live in poverty.

These are among the most deprived people in China, but on a Monday morning last month it was quiet and half-empty. After years of neglect patients are only slowly returning to the hospital, which re-opened in December.

"Our biggest task is first to restore people's confidence in the health care system," explains Dr Marcel Roux, head of the Medecins Sans Frontieres (MSF) mission on the mainland, whose determination has created the most ambitious non-governmental health project in China.

He had to persuade MSF, the winner of this year's Nobel Peace Prize and which traditionally deals with humanitarian emergencies, to spend $ 62 million over five years to restore the hospital and five clinics and sponsor the retraining and equipping of local health workers.

"It is difficult for Westerners to realise what sort of a crisis we have in rural China," Dr Roux said. "Now we are going to the villages we are starting to understand. The level of health care is less than basic. Health care is better in Africa, for sure. There, people are organised and there are good African physicians and health workers but in China, they don't have the knowledge, the structures or people to make it work."

His views are a shock to those familiar with the romanticised vision of Mao Zedong's barefoot doctors who made China a model for the developing world.

Since then the countryside has experienced "an anarchic privatisation", as Charlotte Cailliez, a researcher at the School for Advanced Studies in Social Sciences in Paris, puts it. "The state has withdrawn from health care in rural China."

In 1978, a fifth of the health budget went to rural areas but by 1993 just four per cent was spent on caring for the poorest quarter of the population. By 1996, when new policies were launched, 90 per cent of peasants were not covered by health insurance.

Years of neglect and underfunding reduced the entire system to such a state that the mainland authorities were reluctant to allow foreigners to witness it. MSF came to Guangxi in 1996 to help after floods ravaged Liuzhou, an industrial city and the prefecture's capital. They struggled to gain officials' confidence.

"We dined with public health department officials who never even told us there was a cholera outbreak in the city. We only learned about it by catching a public announcement on television," Dr Roux recalled.

Even now, MSF aid workers are closely watched and always accompanied when they go to the villages.

Dr Roux was taken aback by what they saw of the health system. Gongdong Hospital, built in the early 1960s, had become a ghost hospital with broken and rusty equipment. "The biggest danger to a baby being delivered in the operating room was not infection but the roof collapsing," he said. "That was why there were only two or three patients a day. Now there are 20 or 30."

Since the first visit he has travelled to other parts of rural China and believes health care is no better elsewhere.

"You only have to travel 30 miles (50 kilometres) out of Beijing," he said.

Dr Shi Rongsheng, an ethnic Miao doctor who works at Danian township further up the valley, said his clinic was also in a bad state before MSF arrived.

"Everything has had to be repaired. There was not even any water or electricity," he said. Many hospitals were deep in debt and the only revenue came from selling medicine.

"How can people work if they have not been paid their salary for eight months? People like Dr Shi have three children at school and have to pay the school fees," Dr Roux said. Since February, the local government has started to pay the doctors and other staff.

Dr Shi earns 475 yuan (about HK$ 446) a month and says he can earn 10 times as much if he works in a city. In the 1980s, many doctors and nurses migrated to better-paid jobs in the cities and new graduates are reluctant to work in rural areas.

"Even the doctors there have poor qualifications, perhaps one year of training 20 years ago," Dr Roux said.

Diseases which the Government boasted had been eradicated are returning. In Rongshui, this means tuberculosis, hepatitis, dysentery, intestinal worms, Japanese encephalitis; elsewhere it means leprosy, cholera and typhoid.

Dr Shi said: "The TB started in the 1980s, perhaps we now have 300 patients in Danian. Under the commune system it was better because there were one or two responsible health workers who would isolate a person if he became sick."

Without any way of gathering statistics, Dr Shi has no real knowledge how fast the disease is spreading. According to official statistics, six million are infected and there are 900 TB deaths a day.

The crisis forced a review of policies in 1996 and Beijing announced plans to revive the rural health system by retraining doctors, re-establishing village health insurance systems and boosting government expenditure to five per cent of gross domestic product.

Dr Liu Tangwei, deputy director of the Guangxi Public Health Bureau, said: "Our province decided to spend 10,000 yuan re-equipping every village co -operative health clinic."

Villagers are each supposed to contribute five yuan into a fund to insure themselves against emergencies costing more than 200 yuan. "It has existed since 1997 but the villagers don't want to put any money into it. Some don't trust it at all. Besides, if there are just two emergencies, all the money will be used up," Dr Roux said.

Even to gain admission to hospital, local peasants are required to pay a deposit of 1,500 yuan and sometimes 3,000 yuan.

"In some places, it will take at least five or 10 years to reach the previous level of health care," Dr Shi said.

MSF is busy retraining the barefoot doctors, drawing up and distributing a list of essential medicines, regulating fees and ensuring wages are paid on time. Morale is slowly recovering.

Last month MSF held a ceremony formally re-opening the clinic at Danian, with speeches by dignitaries including French and Japanese diplomats. A charity run by the Japanese Post Office Savings is helping to fund the project.

The small team of foreign staff led by French doctor Philippe Legall needs to persuade locals to start using the clinic instead of cures offered by growing numbers of shamans.

"The worst thing is that they can't afford any medicines. Or they buy a course of antibiotics but only enough for one day so it is useless," he said.

Inside a ward was a woman whose 40-day-old baby was running a high fever. She said she borrowed money to pay for treatment. "The hospital is like a mountain for us. We know we can rely on it," she said. Slowly, the distrust of the local officials is giving way to a grudging acceptance of the presence of the foreign aid workers.

After the gaily attired Miao youths finished their dances before the guests assembled on the podium in Danian square, the chief of public security paid tribute to MSF: "They have already saved many lives here, and they have (given) us new ideas and concepts of modern civilisation and humanity."