Health experts say the SARS crisis that has sickened thousands of people in China and killed hundreds reveals deep flaws in the country's medical system. Rural areas suffer the most, they are home to most of China's people, but few of its hospitals and doctors.
At the edge of a village north of Beijing, an elderly man with a hand-written sign and a red flag turns away cars coming from the capital.
Like thousands of other unofficial guards in villages around China, he is keeping out cars that might be bearing SARS along with their passengers. Some villages look as if they are prepared to fight off an invading force.
So far, China has not reported large numbers of Severe Acute Respiratory Syndrome cases in the countryside, and officials say strong quarantine measures may keep it that way.
But health experts and poverty-stricken villagers alike worry that the sometimes-deadly SARS virus could spread quickly in the countryside, where there are few resources to fight it.
Of the more than 8,300 SARS cases worldwide, more than nine percent, or 760, of them proved fatal. But most of cases have been in cities, where hospitals have respirators and expensive drugs to keep SARS patients alive.
China's rural communities often lack even basic equipment such as X-ray machines, and are chronically short of medical personnel. Without modern equipment and skilled doctors and nurses, experts say there would be little way to halt the spread of the disease - or keep alive those who catch it.
It is a huge concern because 800 million of China's 1.3 billion people live in rural areas. And over the past two decades, they have seen their health-care facilities deteriorate.
Professor David Lampton studies Chinese politics at Johns Hopkins University in the United States. He says rural health care problems are the unintended consequence of China's shift over the past 25 years from a communist planned economy to a more market-oriented one.
The change brought dramatic economic gains for coastal cities. Rural areas, however, have been left far behind. "China, in its race for development in the last two decades, has particularly neglected rural public health and the public health care system," he says.
After the communists came to power in 1949, they set up a health-care system that nearly doubled life expectancy from 35 to 69 years and sharply cut the mortality rate for newborn children.
The communist government sent out thousands of "barefoot doctors" with rudimentary medical training to bring basic sanitation and immunizations to the countryside. Rural communes and work units provided health care at little or no cost.
Those systems are gone. Now, hospitals and doctors charge hefty fees, putting treatment out of reach for impoverished rural residents.
There are indications that infant mortality now is rising in the poorest areas, where minority groups live. Limited access to health care also may be to blame for small outbreaks of diseases once thought under control in China, such as snail fever, hepatitis, bubonic plague, and diphtheria.
Keiji Fukuda is a World Health Organization disease control expert. He says SARS is forcing China to put more resources into health care. "There really is an acknowledgment by the government that public health has languished in China for a number of years," he says. "And I sincerely hope that this is the beginning of the strengthening and rebuilding of the public health care system in China."
Chinese health officials recently pledged $350 million to set up a nationwide disease reporting system and more money to fix other problems.
Chinese scholars say the money will help, but may not solve the problems. The wealthy, and politically influential, coastal cities have been able to grab a disproportionate share of health-care resources. It is not certain that rural areas will be any more effective at getting medical money in the future than they have been in the past.
A professor of international health at Harvard University, Liu Yuanli, says China's government is trying some new ideas that may help fix the rural health-care system. About six months ago, officials began testing insurance plans for farm communities. He says the lessons from those projects will be applied in larger insurance programs in the future.
Professor Liu says the spread of SARS around the world shows it would also be a good investment for the international community to help China fund a health care system that could keep SARS and future emerging diseases under control. Other experts warn that the next disease to emerge may be even more dangerous than SARS.
