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Balancing China’s basic rural health needs—perspectives from public health practitioners

Guest blog by Angela Ni, Fulbright Fellow 2010-2011, Yunnan, China (
When I first met Doctor Zhang he was sitting behind his desk prescribing medicine to a young boy suffering from a respiratory infection. Zhang is a village clinic doctor, part of China’s frontline force for rural illness and injury. Zhang’s father was a barefoot doctor, and at the age of 19, Zhang himself was trained in this famed Chinese tradition of door-to-door healing. Over the last 45 years, Zhang has witnessed the dynamic transformation of China’s rural medical system from complete collectivization to that of a profit-driven, fee-for-service system. Zhang’s village clinic, where the old clinic facade still exists next to the recently built clinic, is a physical reminder of the dramatic change that has occurred in China’s rural healthcare system in less than one generation.

Village clinic, Midu County, Yunnan Province, China
Village clinic, Midu County, Yunnan Province, China

In order to better understand the changes and challenges to village health institutions, I recently met public health bureau officials and village clinic doctors in Yunnan Province’s Dali Prefecture. In the past several years there have been monumental improvements in China’s healthcare situation, including a threefold increase in the number of people covered by health insurance. On the other hand, I learned that the work of Zhang and his counterparts in local township hospitals and county health bureaus is still constrained by endemic and structural public health issues. In this blog I examine two key systemic constraints to promoting improved health services at the local level: water conditions and the dearth of quality medical professionals.
Providing drinking water and toilets are two the most cost-effective, but underutilized, public health interventions. As I have previously written, China has benefited from official campaigns to scale-up the use of “eco-toilets” and anaerobic biogas digester toilets. A host of Chinese government agencies have stepped-in to subsidize village upgrades to water and sanitation infrastructure such as piping, public toilets and wells. The risk of continuing to provide subsidized infrastructure is that villagers often receive insufficient training to maintain the technologies installed and do not recognize the upkeep of these technologies as a collective responsibility. There is a running joke in the countryside that when something breaks down, villagers go to the government officials saying, “your pipes broke.” Projects lack a sense of ownership and communal participation.

An alternate scenario is Zhang’s village which has not received government assistance to build eco- or biogas-toilets. Instead, villagers continue to use open, dry pit latrines that do not adequately separate users from feces. For instance, farmers are supposed to let the feces compost for at least 30-40 days before using it as fertilizer. During the height of the farming season, however, farmers in need of greater quantities of fertilizer will often directly spread raw waste onto their crops. In the hot summer seasons, Zhang sees a spike in patients with diarrhea. He blames the increased diarrhea instances on flies that spread waste pathogens to food after coming into contact with untreated waste in the uncovered latrines. Zhang also pointed out that people in his village do not consistently boil their drinking water, either because they are trying to reduce costs by purchasing less fuel or spending less time collecting fire wood.

Sign from clean drinking water campaigns reads “the more pure, the more at ease.”
Sign from clean drinking water campaigns reads “the more pure, the more at ease.”

A sign promoting clean drinking water hangs on the wall of one county health bureau director’s office. The bureau director acknowledged that several years ago only one out eight samples from local fresh water sites met quality standards. The county’s water provision has since been transferred to a privately owned and operated company that was required to meet water quality benchmarks at their initial opening. The county health bureau has yet to perform a follow-up inspection to ensure that the company’s water still satisfies drinking water standards.
When asked about further testing of water quality standards, the health bureau director lamented that his resources are spread too thin by the health mandates continuously handed down by the central government. Gaps in public health oversight are further compounded by the lack of medical professionals trained to carry out public health campaigns. During my visit, the most recent buzz surrounded a Ministry of Health initiative mandating all villagers over the age of 65 be tested for chronic diseases such as high blood pressure and diabetes. Completing one such campaign can completely fill the time of a health bureau’s entire staff.

The bureau director said he has been trying for years to recruit recent graduates from the provincial medical and technical schools to staff his township and village clinics. However, the remote locations of health centers and lower pay compared to cities means that he can only attract less qualified talent from second tier training schools, or else rely on the old cadre of clinicians like Doctor Zhang.

Back in his village, Zhang says he will continue to practice his lifelong trade of medicine and healing. While Zhang no longer goes door-to-door treating patients as he used to as a community barefoot doctor, the door to his clinic office is always open to patients; some days he stays late into the night making sure he has seen every last person before returning home. But there is only so much he can do to help patients until more consistent investments are made to improve water and sanitation conditions, as well as provide the human resources necessary to China’s rural healthcare system.

  1. Dear Angela,
    I am not a professional, just an interested citizen who wondered about human waste disposal as I traveled throughout the world as a flight attendant, now retired. I admire those of you who are tackling this unpopular issue. I have TVO’d the “Toilet Crisis” and am watching it in small doses….it is pretty gross, but a subject that must be addressed. I have been telling friends for many years that this is the true medical issue that is going to cause major epidemics in this world….my friends tend to travel to the large cities, stick to the tourist traps and restaurants, and never venture into the “bowels” of a country where the real people live and where the real people are. We had a friend who traveled to AFrica and returned with a sickness that they could not specificallly diagnose and she died. We elitist Americans are not exposed to various bacteria, and therefore have not built up an immunity to those illnesses that natives of those countries may have. Some people are very cavalier in their approach to travel and will have a rude awakening (or killing) as did my friend. Keep up the good, necessary, unsung work.

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