Unhappy Returns

Xin

min is a village on the verge of extinction. Nearly every resident of this swampy, 1,000-strong hamlet in the central Chinese province of Hunan is infected by the parasitic worm Schistosoma japonicum. It spreads through the bloodstream, lays eggs in the liver and bladder, wriggles into the brain or embeds itself in the spine. Renal failure and paralysis may follow; death is painful and untimely. That is the grim fate awaiting Xinmin villager Wang Zengkun. The 45-year-old rice farmer first experienced the stomach cramps and bloody diarrhea that signal schistosomiasis three years ago. For a while, Wang fought the disease by spending his life savings, some $4,830, on medication and operations that removed calcified egg deposits and polyps from his body. But earlier this year, when doctors told Wang that he needed more surgery, he had to forgo it. He had no money left. Wang is not alone. Four of his neighbors who lived along the fetid stream that oozes with microscopic Schistosoma worms—the vectors are freshwater snails—have died in recent months. "The government does not care about us farmers, only about economic development," says Wang, cradling his distended belly with gnarled hands. "There's no one to protect us anymore."

Half a century ago, Chairman Mao Zedong, himself a native of Hunan province, declared war on the diseases ravaging China's countryside. One of his major battles was against the fearsome Schistosoma fluke, which infected 12 million Chinese in 1949 and, according to the World Health Organization (who), is still the world's second-most-debilitating parasitic disease, after malaria. Employing troops of pesticide-wielding workers to eradicate snails and offering free health checkups and medicine for all those living in the schistosomiasis-prone Yangtze River region, China slashed the number of victims to 2.5 million in 1975. By 1988, that had shrunk even further, to 400,000. So proud was the Great Helmsman that he wrote a poem, called "Sending Away the God of Plague," commemorating the People's Republic's fight against a tiny worm.

But beginning in the 1980s, as China's drive to capitalism kicked into higher gear, Beijing extended market reforms to health care—with disastrous consequences. Local health bureaus were stripped of their government funding and forced to become financially self sufficient. To survive, many local clinics eschewed public-minded immunization drives for more profitable ventures, like selling medicine and services at inflated prices. The social pitfalls of this system were laid bare in a 1998 United Nations-led survey, which found that almost half of those who had fallen below China's poverty line did so only after suffering from a major disease. Today, just 15% of Chinese have health insurance. The nation's recent SARS crisis served as another reality check; crucial weeks were lost because only a trickle of funding had gone to important but money-losing services, such as outbreak response and epidemiological research. Despite the lessons learned during SARS, the nation's 4,000 local centers for disease control (CDCs)—key institutions on the front lines of China's battle against disease—still must privately finance more than 50% of their budgets, according to the who, whereas similar institutions in most other nations are government funded. Says Lisa Lee, a medical officer with the WHO in Beijing: "China's health care focuses on how to maximize revenue, not coverage."

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Many infectious diseases that were nearly tamed during Mao's era are now rebounding or, at the very least, the battle against them has stalled. Schistosomiasis is just one example. Diseases like tuberculosis and hepatitis B, which could have been curbed by a more public-minded health-care system, are now spreading largely unchecked. China has had a cheap vaccine for hepatitis B available since 1985. But local health bureaus were loath to offer it free of charge, because the vaccine was a crucial source of income. As a result, 10% of Chinese are now carriers of the potentially fatal liver disease, compared with less than 1% of Americans. Even today, China is the only one of the 37 nations in the's western-Pacific region that requires its citizens to pay for routine childhood immunizations. "During the past 20 years of reform, the government only focused on economic development," says Song Wenzhi, a professor at the Peking University Public Health Institute in Beijing. "It neglected social issues, such as health." No surprise, then, that a 2000 who study ranking the health systems of 191 member countries placed China 144th, behind Indonesia and Bangladesh.

Such chronic neglect has decimated villages like Xinmin. By the early 1990s, local health workers no longer had a budget to spray antisnail pesticide around Dongting Lake, where Xinmin is located. Free schistosomiasis checkups and medicine stopped as well. Now funding for local clinics once proudly designated as "antisnail-fever bureaus" has also dried up; to make ends meet, many have opened up moneymaking clinics for sexually transmitted diseases and osteopathy. Consequently, just as China was proudly announcing that it had defeated snail fever, the mollusk began returning. Last year, according to statistics from the Ministry of Health, 810,000 people contracted schistosomiasis, more than double the number of cases in 1988. But experts caution that the real figure is much higher and could spiral further upward upon completion of the Three Gorges Reservoir, which might cause the snails to spread eastward. Jiang Changzao, a former official at China's largest reed plantation, which supplies pulp for paper, says that almost every reed cutter working the fields near Dongting Lake is now infected with schistosomiasis. He charges staff at the local health bureau with consistently underreporting the number of people infected in recent years in order to meet quotas on snail-fever prevention and to land year-end bonuses. "The local government is lying about the number of people with the disease to make itself look good," says Jiang, who has contracted schistosomiasis himself. "But I am a member of the Communist Party, and I feel it is my duty to report the truth."

Underreporting is also rampant among China's 100 million-strong migrant population, which relies on health care from unlicensed fly-by-night clinics that rarely report epidemiological figures to local CDCs. The who estimates that one-third of China's measles and tuberculosis cases are never reported, in part because they disproportionately affect migrant workers. Without access to proper health care, these itinerant communities are virtual petri dishes of disease. Recent outbreaks of measles and Japanese encephalitis in the southern province of Guangdong—where SARS first appeared—are believed to have originated in this so-called "floating population." An article this year in the U.S.-based Journal of Infectious Diseases reported that the number of people getting measles in migrant populations was almost eight times higher than in resident communities, largely because migrants are either too broke or too disenfranchised to get routine childhood immunizations. Indeed, two of China's poorer neighbors, Vietnam and Mongolia, boast higher rates of routine childhood immunization than China, because of their greater public-health commitment. "All of the international organizations in China have sent clear signals that the public-health system needs to be reformed," says the WHO's Lee. "But so far, we've had almost no response."

Back on Dongting Lake, a reed cutter surnamed Song is resigned to the worms invading his body. During the colder months he serves as the plantation's caretaker, living in a makeshift lean-to made of reeds. One of the few ornaments inside his cramped quarters is a portrait of antidisease crusader Chairman Mao. Outside, the ground is littered with the shells of snails whose worms infect workers in warmer weather. Song's drinking and washing water, drawn from a brackish pit by his hut, also teems with Schistosoma worms in the summer. Naturally, Song has been diagnosed with snail fever. He doesn't feel the symptoms yet, but he knows they will come—as they have for nearly everyone he knows.

"I will get sick," says Song, who cannot afford proper treatment. "But I have no other choice for a job." The God of Plague has returned to Mao's home province, with a vengeance.