A Barefoot Doctor’s Empty Bag

SHILONG, China -- An old peasant clutching a long pipe burst into hacking coughs. He took a few deep drags, then hacked even louder.

“Don’t worry, he’s been coughing like that for years. He doesn’t have feidian,” said Zhu Zhongwen, referring to the Chinese word for SARS, or severe acute respiratory syndrome.

Zhu is Shilong’s “barefoot” doctor, a relic from the era of the people’s commune. He barely finished elementary school, yet for more than 30 years, this 68-year-old farmer and his rickety shelf of bottles and pills have been this central Chinese village’s primary source of medical care.

Though the SARS outbreak appears to be coming under control in the world’s hardest-hit country, concerns linger over the possibility of new cases and what would happen if the illness spread from the cities to the vast countryside.

There, barefoot doctors like Zhu are the first -- sometimes only -- line of defense against this sometimes-fatal new disease with no known cure. The prospect terrifies Zhu, who acknowledges that he wouldn’t know how to treat any serious ailment.

“If the epidemic hits the countryside, they would have no choice but to wait for their death,” said Zhong Dajun, an independent researcher based in Beijing. “There is no way for the countryside to react to such a crisis.”

The son of a village calligrapher who inherited his father’s stylish penmanship, Zhu was considered a promising candidate in the early 1970s when the village recruited barefoot doctors. The name had nothing to do with podiatry and a lot to do with Chairman Mao, who apparently loved the idea that peasants toiling in the rice paddies in their bare feet could trade in their plow for a needle and thermometer and heal the sick.

Zhu had just come home from chopping firewood when his mother, a seamstress, suggested that he take the aptitude test.

“They asked me, why does a train run so fast?” Zhu recalled, standing in front of his home in a faded Mao jacket and knitted purple slippers, a couple of decayed front teeth visible. “I’d never seen a train before, so I racked my brain.”

Whatever he came up with was apparently good enough. With a few basic classes and a wooden medicine box, he set off to help dozens of farmers a day, charging a nominal registration fee and giving out medication for free.

Until market-oriented reforms began transforming China about two decades ago, practically every village had its own barefoot doctor, who became the symbol of a nearly universal health-care system. Though never more than basic, the system was considered one of the crowning achievements of Communist China. Over the course of two decades, communicable illnesses ranging from smallpox to sexually transmitted diseases were essentially eradicated and life expectancy in this largely agrarian society increased from 35 to 65 years.

But by the time Zhu’s four children had grown, capitalism had taken China by storm and cradle-to-grave social services became a memory from the collectivist past. Public subsidies tumbled, especially for rural health care, while costs soared beyond the ability of peasants to pay. Old enemies, from tuberculosis to hepatitis, reappeared.

Today, about 90% of the peasants have no medical insurance, and many consider a trip to the doctor, with shoes or not, the quickest path to bankruptcy. They will ignore small problems and hope the big ones won’t kill them.

“Now I see very few patients because people have to pay for it and I don’t have much to offer,” said Zhu, who lives in a weather-beaten corner of a once-splendid mansion that was confiscated from a wealthy landlord after the 1949 Communist revolution.

Zhu does his doctoring in a damp bedroom next to an antique, carved-wood bed passed down by his mother. His meager medical supplies are stacked on a shelf above an old desk, looking like offerings on an altar. He added disposable needles to his simple stock of aspirin and antibiotics only last year. Before that, he reused needles that he cleaned with an alcohol swab.

Last month, Zhu made the equivalent of $6 selling cold medicine by the pill and giving clients an occasional injection. Not that he could do much more if his patients needed it.

Ask him if he’s ever saved a life and he’ll shake his head and tell you no. “I don’t dare treat serious illnesses,” he says. “I don’t know how.”

Although only a small number of rural SARS cases have been traced to migrants returning from the cities, the mere possibility has shattered the tranquillity of this backwater. Shrouded by bamboo groves and bathed in fresh mountain air, Shilong crouches along southwestern Chongqing near its border with Sichuan province in the Chinese heartland.

At least a third of its 3,000 able-bodied residents have gone to the cities in search of work. Much to the dismay of villagers who stayed, some who left -- and then became too frightened of SARS to stay in the cities -- have been trickling back. They scale walls or use back roads to avoid officials who would quarantine them as a precaution.

The first time Zhu heard about SARS was in April, when officials in Beijing confessed to lying about the extent of the outbreak and called for a national war against the virus.

It’s hard for him to keep up with what is going on. Television is his main source of information and he must tussle with his wife to watch the news every night. She is addicted to drama shows and has no stomach for hearing the latest SARS reports. Most nights she wins, even though he is responsible for monitoring possible cases of the illness.

The job has become so time-consuming that Zhu had to abandon the family fields during the harvesting and planting season. Wearing yellow plastic flip-flops, he walks from meeting to meeting, house to house, searching out potential SARS carriers.

Because the village is so poor, Zhu has not even been supplied with surgical masks, which are ubiquitous in large Chinese cities. He only has one cotton mask, which he paid for with his own money. Having shelled out 50 cents, he washes it and hopes to reuse it for as long as he can.

Zhu is conscientious -- but realistic about the impact he would have if he comes across a case.

“I don’t dare make the diagnosis,” Zhu said. “I just report them to the village clinic. They don’t dare make the diagnosis either. They have to report it to the town and county hospitals, which then have to pass it up to the next level. By the time they finally figure out the person had SARS, it could have already killed him.”

Dealing with returnees isn’t easy. “One woman told me she came back from Shanghai, but her mother said she worked in Jiangsu,” the frustrated doctor said. “I asked her for her train ticket, and she said her mother washed it in the laundry. She told me she’s been examined a thousand times and who am I to tell her what to do?”

All returnees and their relatives are potential suspects, and next of kin are obliged to report on one another’s health and whereabouts.

“I ask my students every day to raise their hands if any of their relatives have come back from the cities,” said Xie Zuyun, a teacher at the village elementary school. “If only one of their parents turns out to be sick, they could infect the entire school.”

The fear alone is contagious. One farmer with a returning migrant son demanded that he walk on a different stretch of dirt road to keep a safe distance.

Zhu’s own son returned unexpectedly from Beijing just as his father was racing to another SARS meeting. The doctor hardly paused to glance at the 27-year-old construction worker, who was handing out candies to kids near the village entrance.

“I had no idea he was coming home. He never called,” Zhu explained. “I told him to go get himself checked up. I don’t dare take his temperature. I don’t want to be accused of harboring my own son.”

A few days later, the son reluctantly agreed to be locked up at home for two weeks even though he showed no symptoms of SARS. His mother shoves bowls of rice to him through a crack in the door to his room.

One little girl who confessed that she stopped to chat with Zhu’s son as he gave out sweets has been yanked out of class and sent home to be isolated, too.

“They should know better than to come back,” Zhu said. “We have nothing here to offer them.”