告别“赤脚医生”中国农民受苦 Without 'Barefoot Doctors,' China's Rural Families Suffer 告别“赤脚医生”中国农民受苦 【多维新闻社14日电】多维社记者齐文信报道/过去十多年来，随著“赤脚医生”制度被 取消和农村免费医疗制度的解体，中国八亿农民的医疗保健条件急剧下降。农民无钱看病 已经成为中国市场经济改革中的副产品。(chinesenewsnet.com) 纽约时报14日说，随著中央政府退出人民生活，他们也取消了对医疗和教育等社会服务的 大部分补贴，希望地方财政填补这些空白。但后者根本没有。(chinesenewsnet.com) 中国农村的医疗体系成为医院和私人诊所的混合体，但共同特点就是收费很高，看一次感 冒就要两个月的收入，在医院生孩子要花费两年的现金收入。(chinesenewsnet.com) 根据联合国还没有公开发表的报告，中国医疗费用在1990年和1997年之间增长四到五倍， 许多地区的农民，除了特别紧急情况，干脆不去看医生。他们忍受病痛折磨、长期发炎、 在家冒险生孩子。(chinesenewsnet.com) 研究人员说，疾病是中国家庭跌落到贫困线之下的首要原因。(chinesenewsnet.com) 文章以云南Bazuo农民张友莲(音译)为例说明贫穷地区农民遭受疾病折磨的悲惨景象。张 友莲35岁的丈夫长期胸疼，但一直忍耐，后来被别人把他从稻田里送进医院，死在急诊室。 她四岁的儿子被脱粒机截断了手，她抱著流血孩子跌跌撞撞下山走了几英里，才找到汽车 把他们送到医生那里。(chinesenewsnet.com) 现在，她的儿子已经失去半只手。她还背上相当于500美元的债务，这等于她七年的收入。 (chinesenewsnet.com) 就像中国其它多数农民家庭一样，没有任何医疗保险或者社会福利来支付她的开支。张说， “我不知道如何还帐。”张的邻居陈九香说，“如果病得厉害了，只好借钱去看医生。但许 多人都不看医生，他们太穷，知道看医生要花钱。二十年前可不一样。当时看医生很容易， 也很便宜。即使得了重病进医院，顶多也就是花100元。”(chinesenewsnet.com) 官方统计数字也显示穷人健康状况在恶化。过去15年来，中国结核病增长四倍，过去四十 年来一直下降的婴儿死亡率也在贫穷地区上升。尽管中国政府免费提供免疫疫苗，但由于 农村诊所要收取“管理费”、“针头费”和“针管费”，贫穷地区免疫率也在下降，有些地区 甚至降低到非洲撒哈拉沙漠之南地区的水平。(chinesenewsnet.com) 中国卫生部农村卫生处官员聂春雷(音译)说，中国整体医疗水平在上升。整个九十年代， 婴儿死亡率都在下降，几乎百分之九十的村庄都有了诊所。(chinesenewsnet.com) 但他也承认发展很不平衡，贫穷地区和西部省份都落后了。在非常贫穷的地区，政府和集 体都没有钱资助医疗事业，农民要承担全部费用。(chinesenewsnet.com) 在中国城市和沿海农村，医疗条件是在改善，许多医院都添置了先进设备。但即使是在城 市，几乎所有人都在抱怨医疗费太高。 March 14, 2001 Without 'Barefoot Doctors,' China's Rural Families Suffer By ELISABETH ROSENTHAL BAZUO, China - As Zhang Youlian wept in the dirt courtyard surrounded by towering peaks, her tears spoke to her year of calamities. First, her 35-year-old husband fell ill and was taken from their rice fields to the hospital with chest pain that he had ignored for too long. Then, her 4-year-old caught his hand in a thresher. Covered with blood and cradling the wide-eyed boy in her arms, she stumbled down miles of steep rocky paths until she found a car that drove them to a doctor. Her husband died in the emergency room. Her son is now missing half his hand. And her personal losses have been compounded by unthinkable debt. Although neither patient was admitted to the hospital, bills for their treatment totaled more than $500, seven times the average yearly income here in their village in southwestern Yunnan Province. And, as with most rural families, there was neither medical insurance nor welfare benefits to cover the costs. "I borrowed it from family members," Ms. Zhang said. "I don't know how I'll pay it back." Huge numbers of China's 800 million rural residents are in a medical free fall, as the once-vaunted system of "barefoot doctors" and free rural clinics has disintegrated over the last decade, a side effect of successful market-oriented changes. As central government planners have withdrawn from people's lives, they have taken with them most subsidies for social services like health and education, hoping that local coffers and initiatives would fill the gap. They have not. The rural health system has become a hodgepodge of hospitals and clinics that are often privately run and almost always prohibitively expensive, where treatment for a cold can eat up two months' income and giving birth in a hospital two years of hard-earned cash. With health costs that increased 400 to 500 percent from 1990 to 1997, according to a new United Nations report, medical care in many rural areas is so costly that people have stopped seeing doctors except in extreme emergencies. The ill endure pain, chronic infection and the risks of childbirth at home. Illness is the leading reason why Chinese families fall below the poverty line, researchers say. "If you are really sick, you borrow and go to the doctor," a neighbor of Ms. Zhang, Chen Jiuxiang, said. "But most people still don't want to go, because we are poor here and they know it will cost a fortune. Twenty years ago it was different. It was easy to see the doctor and cheap, too. Even if you had to go to the hospital with a very serious illness, it would cost at most 100 yuan," or $15. Health statistics are beginning to reflect the large numbers who now do without. The number of tuberculosis cases has quadrupled in 15 years, and infant mortality, which had been declining steadily for most of 40 years, is beginning to creep up in poor areas, according to the United Nations report, which has not been officially released. Although government outreach programs in remote areas once gave China immunization rates that were the envy of the developing world, the effort has started to slip. "Coverage is uneven in poor areas such as Shanxi and Guizhou Provinces, where measles coverage is as low as in many sub-Saharan African countries," the report said. Many Chinese echo that assessment. "China is not achieving its own basic health criterion," said Prof. Zhu Ling, an economist at the Chinese Academy of Social Science who has been studying health care. "People aren't getting basic health services because they can't afford them." Dr. Nie Chunlei, deputy director of the Rural Health Division in the Health Ministry, emphasized that indicators had continued to improve for the country as a whole. Infant mortality decreased throughout the 1990's, and almost 90 percent of villages have at least one clinic. But Dr. Nie acknowledged that "development has been very imbalanced," with poor farming areas and less-developed western provinces left behind. "In very poor places," he said, "the government and the collective don't have the money to subsidize health care, and so the peasants have to pay it all. In many cases, they don't have the money to see a doctor." In cities and more prosperous coastal farming areas, health care has improved in the last decade, with government hospitals offering more sophisticated tests and specialized medicines. Still, even in cities, just a minority of residents has comprehensive coverage, and nearly everyone grumbles about increasing costs. The situation is far more dire in the vast poor rural regions, where local officials had neither the money nor expertise to maintain a health system after central government assistance had dried up. Many areas simply cut loose government clinics and hospitals, requiring them to support themselves. Today in rural areas, an increasing number of clinics are privately owned for-profit ventures that set their own rates, and even state- owned clinics are often contracted out. "In some provinces, there is no system left, and it's every man for himself," said a Chinese health expert who works at a state research institute. The Health Ministry has acknowledged the problem and has helped local governments develop pilot projects to address it. But budget cuts have reduced its staff by 45 percent since 1998, and there has been little concrete progress. The government still limits the doctors' consultation fees to 60 cents a visit, a sum that has not changed for decades despite inflation. But there is little regulation of charges for medicines, injections and tests, which are prescribed in abundance. Market forces have brought modern medical technology into the countryside. Clinics in remote rural villages now dispense a wide variety of Western drugs. Even small county hospitals have CAT scanners. But in poor places like Bazuo, such fruits of progress are generally out of reach. The United Nations report said even a simple hospital stay could cost more than the yearly income of most peasants. Song Youzhi never saw a doctor when she was pregnant with Wang Xiaorui, now 3, because, she said, "I felt O.K." When contractions began, she stayed at home and gave birth with the help of a relative. Nearly all the women in Bazuo give birth without prenatal care, in unheated houses with no running water. Some are deterred from seeking medical help because their mud- brick houses are hours away by footpath from the dirt road that zigzags down the mountain to the township hospital. But for others like Ms. Song, who lives quite close to the hospital, the issue is money. "Of course, it's safer and more comfortable in the hospital," Ms. Song said. "But it's too much money - 600 to 700 yuan. And I didn't have that." She added that her family earned $60 a year growing ginger and red peppers. By discouraging expectant mothers from seeking professional help, such fees have contributed to high rates of infant mortality and women's deaths in childbirth. In the county that includes Bazuo, children died before their 5th birthday at a rate of 64.7 per 1,000, twice the national average. In some parts of Yunnan Province, the rate is as high as 200 per 1,000, meaning that one of every five children will die before turning 5 years old. Although the Health Ministry would like all women to give birth in hospitals, the United Nations report estimates that 29 percent of women in poor counties can afford prenatal examinations and that 6 percent can afford hospital deliveries. In counties where pilot projects have reduced hospital charges for childbirth, the percentage of hospital deliveries has more than doubled. But experts say many women are reluctant to spend any money in rural health centers because conditions are often poor. Chinese health researchers say the new market-driven care offers few advantages to hundreds of millions of rural poor. And, they say, the new setup fails at tasks that the old system performed so well like public health campaigns and immunization drives. Self-supporting clinics cannot make money trekking out to distant villages to vaccinate children or exhorting women to obtain prenatal care, they said. Although Dr. Nie of the Health Ministry said immunization rates remained very high, he added that in remote areas the lack of vaccinations was becoming "a very serious problem." Although a basic immunization set is still technically free, patients often pay "administration fees," as well as fees for needles and syringes. No new immunizations have been added to the free program since 1978, not even hepatitis B vaccine, which would help fight a disease that is endemic in China. Professor Zhu, the economist, has proposed that the central government allocate money from its antipoverty program to underwrite rural care. Some basic and preventive services need to be free for poor people, she said. Otherwise people will not receive them. At the urging of the central government, additional cities and prosperous rural counties, where farm income is supplemented by small businesses, are developing fledgling insurance plans or cost-sharing programs, under which a local government may pay parts of medical bills, Dr. Nie said. But even there, the local governments contribute at most half the cost, and Dr. Nie acknowledged that the model would not work in much of the country. "Finance is a very difficult question," he said. "We've been thinking a lot about this in the last two years. But the central government doesn't have the resources to solve this alone. It can't bear the cost." Copyright 2001 The New York Times Company