China's critics tend to be those countries most threatened by China's economic growth (i.e the US and it's client states like Britain and Japan - Australia certainly has no complaints). This modern version of Cold War rhetoric usually takes the form of seizing one of several sticks with which to beat China: Tibet (a dying issue), the one-child policy (also a dying issue) even the alleged "military build-up" in China (which, given the US spends 20 times more on defense than anyone else, also falls flat). However, three issues do have the potential to cause China's rulers some grief; pollution, the massive and growing gap between rich and poor and the apparent collapse of the health system (made most apparent by the SARS crisis) that resulted from the Central Government's tendency to regard health as a local issue.

Since 2006 The Chinese Government has been introducing a low-cost health insurance scheme in rural areas but it is too soon to judge it's effectiveness.

Mao's Barefoot Doctors
From Mao's China, a History of the Peoples Republic
By Maurice Meisner, New York 1977

The Cultural Revolution also has resulted in a significant shift of resources and a very large shift of emphases, from the cities to the Countryside in two other vitally important areas of Chinese life - medical care and education. In 1965 Mao Tse-tung (Mao Zedong), complaining that doctors were being trained "only for the benefit of the cities" in a country where the vast majority of the population lived in the rural areas, proposed radical measures to remedy the situation:

In medical education there is no need to accept only higher middle school graduates.... It will be enough to give three years [of medical training] to graduates from higher primary schools. They would then study and raise their standards mainly through practice. If this kind of doctor is sent down to the countryside, even if they haven't much talent, they would be better than quacks and witch doctors, and the villages would be better able to afford to keep them.

He also suggested a greater emphasis be put on preventive medicine and the treatment of "commonly seen, frequently occurring and wide-spread diseases" rather than the study of what he called "rare, profound, and difficult diseases at the so-called pinnacle of science." And he concluded, "We should leave behind in the city a few of the less able doctors who graduated one or two years ago, and the others should all go into the countryside.... In medical and health work put the emphasis on the countryside."

The policies pursued since 1969 have followed these proposals, by and large When medical schools resumed normal functioning after the disruptions of the Cultural Revolution, the program of formal study was reduced from six to three years in order to graduate doctors to meet im-mediate needs, and the curriculum revised to deal with the problems that, as Mao had put it, "the masses most need solutions." The new classes admitted for study in 1971 included a far greater number of students from the rural areas, many of them younger "barefoot" doctors who lacked formal education but who possessed a wealth of practical knowledge and experience. The entire national health-care system was radically decentralised, with urban hospitals and medical schools establishing clinics and local teaching institutes on the rural communes and providing doctors to staff them. More mobile medical teams were dispatched to the countryside by urban medical centers and the PLA (which has its own system of medical schools and hospitals), and all city medical personnel were required to serve on such teams or at commune medical centers on a rotating basis. In 1969 the training program of barefoot doctors was greatly accelerated and systematized. Today over a million such paramedics (the number having increased more than fourfold since 1965) are engaged in preventive medicine; providing health education and birth-control information and devices; and treating common illnesses while referring more seriously ill patients to commune or city hospitals. After a six-month period of training by professional doctors in commune or town hospitals, the barefoot doctors return to the local community that selected them for training in the first Place and are paid as ordi-nary peasants on the prevailing work-point system, usually supplementing their medical duties with agricultural work. Periodically, they have the opportunity to receive more advanced and specialized training at profes-sional centers and then again return to the rural community.

The financing of the new, and still evolving, rural health care system is marked by considerable local variations. On some communes, coopera-tive medical plans have been established, covering the costs of most services; members pay a nominal annual premium of one to two yuan (forty to eighty cents), supplemented by contributions from collective commune, brigade, or production team funds. Elsewhere, the individual "fee-for-service' system remains, although the fees are low and often paid from commune or brigade collective welfare funds. The construc-tion of rural hospitals and clinics has been financed by the state in some areas, and by communes in others. The general emphasis in financing is on local self-support and self-reliance, but central government support has been essential for developing a viable rural health-care system. Pro-fessional medical personnel working in rural areas, for example, are on state salaries, the mobile medical teams are state financed, and the costs of training barefoot doctors are largely borne by the state. In all, this has involved a considerable transfer of resources from urban to rural areas, although, by all accounts, the level of medical services in the cities remains far higher than in the countryside.

A Contemporary US view: China Struggles to Rebuild Devastated Health Care System
By Luis Ramirez (Voice of America)
Zhuangzi village, China
01 May 2006

In the first decades of Communist Party rule, China saw life expectancy rise and maternal and infant mortality fall. The reason: a national effort to get basic health care to every village - free vaccinations, antibiotics, and instruction on sanitation, delivered by hastily trained health practitioners known as the "barefoot doctors." The rapid economic development brought by free-market reforms has ironically brought a collapse in the country's health care system. Under-funded hospitals now refuse treatment to the poor, and medical professionals leave impoverished rural areas. Millions are left without basic medical care. VOA's Luis Ramirez traveled to a remote village in China's far western province of Gansu.

A Remote Village in Arid Gansu Province

A four-wheel drive vehicle lurches for hours along dirt roads and through shallow rivers to the village of Zhuangzi - 10 hours by train, bus, and car from the provincial capital of Lanzhou.
The mud houses, cave dwellings, and donkey carts on the parched landscape do not fit with the image of a China whose frantic development has catapulted its economy to the fourth largest in the world.
Alongside the road leading into the village a man, who asked to be identified only as Wang, swings a pick, repairing the road.
Self-trained and unlicensed, Wang is a 63-year-old retired hospital worker who serves as the village doctor. He shows his clinic, a bare room with a concrete floor and nothing more than a stethoscope, a chipped enamel tray with tweezers, and a jar with cotton. He proudly says he has never accepted money from villagers for medical treatment because, he says, no one in this village could afford to pay.
"Hundreds of villagers have come to me," said Wang. "I diagnose them and give them prescriptions. The medicine I have is just common medicine. It can only relieve symptoms. If it is anything serious, there is nothing I can do."

Wang - a self-trained medic treats Zhao Pingan (l) in threadbare clinic

He says many sick villagers simply die, and their relatives sometimes never know what killed them. A man named Zhao Pingan comes to the door to see Wang. Wearing an old, blue communist-style worker suit, he is a frail man who appears to be in his 80s.

He says he is 58 years old but has been crippled by a respiratory infection that might have been easily cured with proper medical care. Zhao says he has been sick for five years and he says it is quite serious. He feels weak and cannot move around much. He has never been to a hospital because, he says, his family is too poor.

The scene in Zhuangzi village is in sharp contrast to the gleaming hospitals of large eastern cities such as Shanghai and Beijing. There, advertisements tout the latest in expensive and often unnecessary procedures such as breast enlargement, eyelid reshaping and other cosmetic surgeries, as well as virginity restoration for women.

Advertisement on a Beijing sidewalk touts breast enlargement and other expensive procedures 

The disparity has been created in part by policies that encouraged hospitals and doctors to seek profits by selling drugs and expensive treatments to make up for the loss of subsidies that were eliminated as part of the country's transition to a free-market system.
With health insurance unaffordable for most people, international health experts estimate about half of China's rural population has no access to hospital services.

The numbers clearly spell out the disparities.
In recent years, the rural infant mortality rate has consistently been more than double what it is in urban areas - and it is rising. Some Western medical journals report the mortality rate among children under five in China's rural areas was 37 for every 1,000 in 1999, and climbed to 39 in 2002.

Experts estimate half of China's rural population has no access to hospitals

For years, China's communist leadership has been trying to close the health-care gap between cities and villages. Their ideas include a low-cost rural health insurance plan, which critics say has reached few people. Public health experts, however, see some hope as the central government has made health care a higher priority in recent months.
Henk Bekedam is the World Health Organization's representative in China.
"The government has already very clearly recognized that they need to so some re-thinking on how best to re-engage in health, and to re-invest in health," said Henk Bekedam.

At the close of the National People's Congress - China's parliament - in March, leaders vowed to spend billions of dollars on improving peasants' access to medical treatment.

However, none of that money appears to have yet reached places such as Zhuangzi village. There in his makeshift clinic, Wang says he will continue to provide free care as best he can, using the meager state pension that he receives every month.
"I was born in the countryside, and I understand how hard life is for farmers," he said. "I think treating patients who are poor is the moral thing to do."

Officials have warned that the health care system's failures could threaten stability at a time when China is already seeing a sharp increase in the number of civil disturbances. However, there are no documented cases where health care issues have triggered major unrest. In Zhuangzi village, Wang says people died even when the barefoot doctors were there and so he asks, "Why should anyone expect change?"