In the Chinese countryside, where 70 per cent of the people live, few choose to see a doctor when they are ill. They cannot afford to. The results are disastrous. The ministry of health says that the reason why nearly a quarter of poor Chinese are poor is because of ill-health. Take just one example: a farmer loses the sight in both eyes, and thus the ability to farm, because he cannot afford the $125 that a corneal transplant would cost.
When the collective economy of the people's communes was dissolved in the 1980s, co-operative medical care collapsed, too. The 90 per cent of the rural population that had been covered by medical insurance dropped to 10 per cent.
Now, at last, things are starting to change. Sars, or severe acute respiratory syndrome, which struck the south-east Asia region two years ago, was a wake-up call for the government. The epidemic killed 348 people on the Chinese main-land - a toll that would have been much higher if the disease had taken hold in the vulnerable rural areas. Even so, Sars cost China $11.3bn in 2003.
The epidemic jolted the Chinese government into devoting resources to reconstructing the long-neglected health system. "A good lesson we have learned from Sars is that we should attach the same importance to public health as we do to national defence," said Dr Rao Keqin, director of the information centre at the ministry of health.
In the early years of the People's Republic, epidemics such as malaria, cholera, smallpox, polio and leprosy were successfully brought under control. But as economic growth overrode everything else, the public health system failed to predict and react to new types and variants of infectious disease brought about by the greater mobility of the population. Sars mercilessly revealed how such diseases could hold economic growth hostage, and cause social panic.
Roughly $1.38bn has been earmarked to help the less developed western parts of China construct facilities to handle infectious diseases. Another $822m has been earmarked for the construction of centres for disease control and prevention.
This contrasts sharply with the low level of government spending on public health over the past two decades. According to Dr Rao, China's overall medical costs rose from 4.1 per cent of GDP to 5.3 per cent between 1991 and 2000, or from $11bn to $59.5bn. However, in the same period, the proportion of these overall medical costs that was contributed by the government dropped from 22.8 per cent to 14.9 per cent, while the share of individual spending rose from 38 per cent to 60.6 per cent. China's government spends less on health than most other developing countries.
A countrywide first-aid network is now being formed to handle public health crises. Specialised wards for infectious diseases are being set up in all general hospitals. Every provincial capital and major city will have at least one hospital dedicated to treating infectious diseases. Information is being circulated more quickly. "It used to take eight and a half days to have a report on a proven case of a listed infectious disease filed from a grass-roots hospital all the way up to the ministry of health," says Dr Rao. "Now the online information system shortens it to one day."
The Sars crisis had the excellent effect of prodding the government into beginning to do something about the majority of its people, who do not have access to even basic healthcare. In the past year it has de-cided to re-establish a type of co-operative medical care system in rural areas. Under this, the government pays $1.20 a year for each individual farmer willing to join the scheme, and the farmer himself puts in the same amount. By mid-2004, the pilot scheme covered 69 million farmers in 310 counties (about 10 per cent of the total).
Sars also opened the government's eyes to another huge and neglected threat hanging over the country: HIV/Aids. Official Chinese estimates say that currently about 840,000 people are infected with HIV. This may be an underestimate: according to the World Health Organisation, China could have ten million HIV carriers by the end of the decade - unless it takes much stronger measures to check the spread of the disease.
In the wake of Sars, the central government budgeted roughly $60m this year for Aids prevention and control, more than three times the amount spent in 2002. The challenge is to identify carriers. Jing Jun, an Aids expert at Qinghua University in Beijing, believes that only 7.4 per cent of HIV carriers are known to the authorities.
In April, the health ministry announced that the government would provide free, anonymous HIV testing and counselling to people in financial difficulties. It has also eased its stern stance on drug use: two-thirds of China's HIV carriers are thought to have contracted the disease by injecting themselves. The government is now sponsoring pilot projects to offer clean needles and methadone treatment to drug addicts. It is also conducting training workshops on safe sex.
In addition, the ministry has started a blanket screening programme for people who sold their blood in the mid-1990s, many of whom became infected from a contaminated blood pool. The pilot programme, in Henan Province, detected 20,000 new HIV-positive people, bringing the total to 80,000 in that province alone.
A vast amount of work remains to be done to restore China's public health to anything like a decent level. But at least the government feels fairly confident that it can cope with Sars if the epidemic were to return this winter. And, thanks to Sars, a greater change may be beginning.
Xiong Lei is a journalist with China Features in Beijing