Economic Liberalisation Destroyed China's Health Service

The early morning in any Chinese park is the time and the place to track the private fears of Chinese citizens. Some come to rehearse their enthusiasms - ballroom dancing, calligraphy or martial arts. Others come to ward off misfortune. Even before the Sars outbreak, the fear of ill-health was enacted in these dawn rituals. In one of the most common, a cheerleader leads a chant as his followers pat parts of their own bodies and urge them to stay strong.

The fear of illness today is well founded. The provision of health services and social security to the mass of the population was perhaps the Chinese revolution's single most important achievement. But even at the height of the communist system there was never a national health service. The provision of medical care derived from a work unit - a factory, a school, a people's commune - that had the responsibility to take care of its workers and their families. It was an arrangement that covered most people, but with Deng Xiaoping's move to a market economy, the system was doomed.

Economic liberalisation meant the end of most of those work units: state industries are closing down, agricultural communes were disbanded long ago and agriculture has been privatised. Nothing has taken their place, and the services the units used to provide have lapsed. Responsibility for public health rests with local authorities which do not appear to have either the funds or the interest to maintain it. Even in the cities, where two decades of economic reforms have brought a general rise in living standards, the burden of medical care is now largely a private responsibility that many can't afford.

So despite increased prosperity, public health has declined. A service that boasted in the early years of the Chinese revolution of having eradicated venereal disease is now almost non-existent. Rural clinics have shut down. Barefoot doctors - primary health workers ubiquitous in the countryside in the 50s and 60s - have largely been replaced by witchdoctors who dispense coloured water and spells.

Scaling back on health commitments was seen by China's reformers as a central part of economic liberalisation. But, as the government found to its cost, if the state does not provide health security, people turn to any promise of health, however implausible. Falun Gong, the religious sect that exploded on to the national scene four years ago, and which the Chinese government has been trying to suppress ever since, owes much of its mass appeal to the belief that it conferred good health on its practitioners.

F or a people who now regard the state as unreliable in matters of health, the handling of the Sars outbreak has brought no reassurance. The leadership seems nervous as it tries to recover from the official concealment of the disease in the early months. As a rule of thumb, the more the party's propaganda department reaches for stale revolutionary images, the less people trust it, and the present crisis scores high on the hoary revolutionary image index. Hu Jintao has threatened that the concealing of Sars cases will be severely punished, but the habit of official secrecy that dictated the initial cover-up, and earned China a humiliating public rebuke from the World Health Organisation, is no more guaranteed to respond to exhortation than those body parts patted by believers in a Beijing park.

The still bizarre pattern of admitted Sars cases suggests that the bureaucracy is embracing transparency with less than wholehearted enthusiasm. Shanghai has admitted very few cases, Guangdong to the south and Beijing to the north have many; some provinces acknowledge that the million migrant workers who have fled Beijing brought Sars with them, others do not.

The Chinese are less likely to believe the official story than the versions they read on the internet or the messages they receive on their mobile phones: unofficial accounts of the extent of the epidemic circulating on both are now rigorously policed and censored.

The Sars outbreak has reminded the Chinese of what has been lost over more than two decades of sustained economic growth, as they discover that dilapidated public health services are in no shape to fight an epidemic, or even to report one consistently. Until Sars, though, the lack of care for the rural poor was no more important to the government than the appalling safety record of the Chinese mines. Even now, it is the fear of international quarantine and the potential economic damage rather than the death rate that has prompted action.

The Chinese government's available weapons against Sars are social and political rather than medical. The state security apparatus, unlike the public health services, has maintained investment and is trying to enforce travel and quarantine restrictions. But as far as reporting and containing the outbreaks goes, Beijing knows that it cannot trust local officials either to act effectively or - even less likely - to acknowledge their failures.

And as the barriers that local people themselves have erected round their villages and neighbourhoods demonstrate, the people know it too.