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China losing protections for poor { January 15 2006 }

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The bottom drops out of a Chinese safety net
By Howard W. French The New York Times

FUYANG, China When Jin Guilian's family took him to a county hospital in this gritty industrial city in Anhui Province after a jarring two-day bus ride during which he drifted in and out of consciousness, a doctor took one look at him and said: "How dare you do this to him? This man could die at any moment."

The doctor's next question, though, was about money. How much would the patient's family of peasants and migrant workers be able to pay - up front - to care for Jin's failing heart and a festering arm that had turned black?

The relatives scraped together enough money for four days in the hospital. But when Jin, 36, failed to improve, they were forced to move him to an unheated and scantily equipped clinic on the outskirts of Fuyang where stray dogs wandered the grimy, unlighted halls.

Economic reforms in China have turned an almost uniformly poor nation into an increasingly developed one in the space of a mere generation. But the collapse of socialized medicine and staggering cost increases have opened a yawning gap between health care in the cities and the rural areas, where the former system of free clinics has disintegrated.

In the last several years, China has experimented with reforms aimed at improving health care for peasants. The most important is an insurance plan in which participating farmers must make an annual payment of a little more than a dollar to gain eligibility for basic medical treatments.

Many peasants have complained that even the dollar payment is too big a burden and that in any event the coverage the plan theoretically provides is inadequate.

The government, which under President Hu Jintao has made rural living standards a top priority, recently announced an expansion of this experiment, with increased fees and increased coverage, but it has yet to make an impact on the health crisis.

As a result, according to government estimates, in less than a generation, a rural population that once enjoyed universal if rudimentary coverage has become 79 percent uninsured. More than half of urban residents, by comparison, have some kind of coverage, which is supplied by their employers.

The near-total absence of adequate health care in much of the countryside has sown deep resentment among the peasantry while helping to spread infectious diseases like hepatitis and tuberculosis and making the country - and the world - more vulnerable to epidemics, like severe acute respiratory syndrome, or SARS.

The failure of the government to provide decent health care for peasants has reinforced the idea of China as two nations: one urban and increasingly comfortable, the other rural and increasingly miserable.

The official news media are regularly filled with accounts of the desperate choices people are forced to make over health care and of brothers who must draw lots to see whose serious disease will be treated because their family cannot afford to treat both.

"There's basically no safety net at all for medical care in the village I live in." said Yang Yunbiao, a worker with a Chinese independent organization in Fuyang that aids poor sick people. "Our village has a lot of aged people with disease who are unable to get treatment, just staying at home in bed with barely enough to eat. They are shut in and can't work, and their disease and poverty have taken away their dignity."

That China finds itself in this situation today is as remarkable as its economic takeoff and, paradoxically, is inseparably related to it. Until the beginning of the reform period in the early 1980s, socialized medical system in China, with "barefoot doctors" at its core, worked public health wonders.

From 1952 to 1982 infant mortality fell from 200 per 1,000 live births to 34, and life expectancy increased from about 35 years to 68, according to a recent study published by The New England Journal of Medicine.

Since then, in one of the great policy reversals of modern times, China has dissolved its rural communes, privatized much of the economy and shifted public health resources away from rural areas and toward the cities. Public hospitals were urged to charge commercial rates for new drugs and most procedures, and today the salaries of health care workers are typically linked to the amount of income they generate for their hospitals.

The recent emphasis on profit, meanwhile, has led doctors and other well-trained health care workers to abandon the countryside, with the result that peasants are left at the mercy of unqualified caregivers and outright charlatans who peddle expensive, improperly prescribed drugs and counterfeit medicines.

In Jin's case, the best doctors could do was to administer oxygen and an antibiotic drip. But the new locale did have one sure merit: With their savings nearly exhausted, of all the places the Jin family had taken their brother in an 800-kilometer, or 500-mile, trek from Guangdong Province, where he worked, it was the cheapest, costing what for them was still an exorbitant fee of about $15 a day.

"We don't want to go anywhere else," said Jin Guibin, an elder brother who spoke at the patient's bedside in his frigid room. "If he dies, he'll die here. If he recovers, he'll recover here. We don't have any other means."

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