Vice-Premier Li Keqiang escorts Zhou Yuehua, a rural doctor, outside after a meeting in Beijing on Saturday with doctors from the countryside who were recognized for outstanding work. Yao Dawei / Xinhua

Zhong Jing, 30, a village doctor from Guizhou province pays a visit to a patient in Longhe village in Guangxi Zhuang autonomous region. She recently won an award as one of the most-respected village doctors. Ou Dongqu / Xinhua

Top: Zhou Yuehua, 43, from Chongqing, who has difficulty walking, visits her patients every day with the help of her husband Ai Qi. Chen Cheng / Xinhua Above: Deng Qiandui, a village doctor in Nujiang prefecture, Yunnan province has spent 28 years accessing his patients by sliding across the Nujiang river.Pan Wenhai / Xinhua

Arduous treks and difficult conditions must often be negotiated before patients in isolated areas get medical treatment, report Yang Wanli and Tang Yue.

Losong Gyaltsen left his home in the Tibet autonomous region on New Year's Eve and set off on his first trip outside the area.

Despite the title "village doctor", the 33-year-old doesn't actually hold a medical degree, but is licensed to provide basic services in rural areas.

He traveled to Beijing to receive one of the awards being presented to China's 10 most respected village doctors, and had already earmarked a number of places to visit in the capital.

Like many people, the young man was looking forward to seeing Tian'anmen Square, but one place he never imagined he would visit was his "biggest surprise" - Zhongnanhai, the residential compound for China's top leaders in downtown Beijing.

Although the January day was sunny, the wind was bitterly cold. Losong Gyaltsen recalled the moment Vice-Premier Li Keqiang entered the room. "I was too nervous to speak, so I just kept saying 'hello'," he said.

The vice-premier met with 18 village doctors from across the country. All work in rural areas, but Losong Gyaltsen was the only one from Tibet. In his 18 years in Shading county, in the east of the region, he has delivered more than 500 babies, many of whom had extremely difficult births.

Serving around 2,000 residents in 16 villages, 13 of which have no access to good roads, Losong Gyaltsen relies on his horse. A one-way trip to a village can take as long as seven days and he is accustomed to carrying supplies of food and water on his rounds.

He often crosses 5,000-meter-high mountains where the winter snow can reach as high as his knees and stones made unstable by the heavy flow of water crash into the ravines far below.

Losong Gyaltsen is among 1 million village doctors operating out of 648,000 health centers and providing treatment for isolated communities. However, low pay, harsh living conditions and a lack of new talent entering the field make life hard for many of Losong Gyaltsen's more senior colleagues, half of whom are aged 50 or older.

Those aged between 20 and 29 account for just 7 percent of the total, according to a 2012 report by the Ministry of Health. The poor working conditions and a negligible chance of promotion mean the younger generation looks elsewhere for more lucrative and easier ways of making a living.

Harsh conditions

"My grandmother died from an unspecified disease. She didn't receive any medical help because of the lack of village doctors. After she died, I decided to attend technicians' school, despite the fact that working in the villages is hard," said Losong Gyaltsen.

The young man is not talkative, but recalling the first time he delivered a baby made him smile shyly. "The patient was in great pain and her family was very nervous. Her first baby had died during a difficult labor. I was scared, but I had to try," he said.

When the woman successfully gave birth to a boy, the family members gathered to offer a prayer of thanks. "I felt so proud. Nothing is more meaningful than a new life," he said.

Losong Gyaltsen made a strong impression on Zhong Jing, 30, a village doctor from the southwestern province of Guizhou who was selected to deliver a two-minute speech in front of the vice-premier at the meeting on Saturday.

"He didn't speak Mandarin very well and it took a few minutes for us to discover his name," said Zhong, recalling the moment she saw Losong Gyaltsen for the first time. "Chinese women are shy and embarrassed to be treated by a man. It is definitely much harder to persuade women from ethnic groups to be treated by a man, especially if he is helping them to deliver a baby."

Unlike Losong Gyaltsen, Zhong already had some experience of meeting high-level officials and had traveled to Beijing on a number of occasions. Last year, she went to the capital four times to receive awards, including that of "excellent young worker".

In 2008, she quit her job at a public hospital in Guizhou and went to serve the 4,000 residents of Longhe village. That came about because her husband had been relocated by his employer, but when he was sent to the provincial capital after just three months, Zhong chose to stay with the rural community.

She recalled the day after her husband left. "Scores of villagers waited outside my house in the early morning. They had prepared rice, chicken and vegetables as gifts, hoping to persuade me to stay. I was told that an 87-year-old villager often thought of me in her last few days. That rarely happens in big hospitals, but the relationship between villagers and village doctors is more like that between relatives," she said.

During the past four years in Longhe village, she has used some of her savings to buy new equipment for the local health center, including ultrasound equipment. About 40 percent of the women in the village have been helped by the equipment she bought.

'Top official'

"On Friday, I was asked to tell one of the 'top officials' about the difficulties we encounter in our work, but it wasn't until the next morning that I discovered the 'top official' was the vice-premier," she said. "I was very nervous. When the meeting started, my hands were sweating so badly that my list of points became a mass of soggy paper," said Zhong.

Zhong told Li that two problems needed to be addressed - a lack of medical insurance to cover potential claims for negligence or accident, and the dearth of opportunities to upgrade their working knowledge.

After working in public and private hospitals for many years, Zhong said village doctors are liable for their own insurance and compensation and one slip can easily bankrupt them. She told how one local village doctor paid tens of thousands of yuan in compensation when a patient died after undergoing acupuncture treatment.

"We dare not to provide a wide variety of services, such as injections. We prefer to give patients traditional Chinese medicine or basic check-ups because of the risks," she said.

Most village doctors in China have studied at technical schools rather than medical colleges, but in rural areas they perform the same duties as general physicians in urban areas. Their job is often demanding because they are often the only option for residents, even in the most severe cases, as poor transport links restrict access to hospitals.

"Village doctors need better training to meet the demand. But in many rural areas even running water cannot be guaranteed, let alone the Internet," said Zhong. "Villagers sometimes ask us to treat their sick chickens, but of course, we don't know how to deal with them."

Low incomes

Zhou Yuehua, a 43-year-old village doctor from Chongqing in Southwest China, has difficulty walking. However, despite suffering from poliomyelitis, an acute infectious disease that causes flaccid paralysis of the muscles, Zhou continues to visit her patients every day with the help of her husband, Ai Qi, who sometimes carries his wife on his back as she makes her rounds. According to Zhou, low pay is a common problem among village doctors.

There are no official data on village doctors' incomes, but some regional health reports suggest that the annual income of a village doctor in western China's rural areas, including the Ningxia Hui autonomous region, is less than $1,604, or sometimes lower than $802 in the remoter areas.

In the coastal province of Jiangsu, a county-level village doctor earns around $2,407 annually. They were once allowed to set their own prices for medicine, but the practice was regulated when China's National Basic Medicine System was introduced two years ago.

"I earn just enough for the basic living requirements of two people, my husband and me. Sometimes, we don't charge senior patients with no wages. Our income would make raising a child almost impossible," said Zhou.

In some rural areas, a village doctor can have more than 1,000 patients, most of whom have difficulty accessing pensions or social insurance systems.

Free treatment

The doctors don't just save the lives of the villagers, sometimes they are also saved by their patients.

In 1998, after three years at a technical school, Li Qianfeng opened a clinic in his hometown of Liuhe in the Guangxi Zhuang autonomous region. He earned about 3,000 yuan ($481) a month and life was comfortable. However, his life changed when he heard about patients from Dalang village, who had to travel for hours to reach Liuhe.

"People told me that some patients weren't well enough to travel that far to see the doctor. Patients who were too fragile to walk were transported to the township on litters dragged by fellow villagers. Some just died halfway through the journey," said Li.

In 2003, he closed his clinic and moved to Dalang village, which consists of eight hamlets. The hamlet furthest from Li's base is 15 km away, but he walks there at least twice a week.

While the workload became heavier, Li's salary shrank. Without a hospital post, he was unable to draw a government salary. At first, he made just 30 yuan a month, although that rose to 300 yuan in 2009, and his profit from the sale of medicines brings in a further 1,000 yuan.

Village doctors are allowed to sell medicine at a profit of up to 15 percent. But Li just charges poor villagers cost price and sometimes provides free medicine for destitute patients.

"It's not just me. A lot of village doctors don't charge for treatment and also provide free medicine to patients unable to pay," said Li, 33. "It may be as little as five yuan. It's nothing to wealthier people, but that sum could provide cooking salt for families for many months," he said.

In May 2008, Li saw things from the patients' point of view when he was diagnosed with uremia, a potentially fatal condition that can cause a kidney failure. Without medical insurance, he had to pay the bill for treatment himself. His family spent all their savings, but was unable to provide the 200,000 yuan needed to pay for a kidney transplant.

When they heard the news, many of the villagers were distraught and brought Li rice, vegetables and fish. They also bombarded the media with letters telling of their village doctor's plight. The letter campaign resulted in donations from the public and HK$930,000 ($120,000) from a charity in Hong Kong. Li underwent a kidney transplant in December 2008.

Although the doctors advised him to give up his work in the villages, he returned two months later. "I felt I owed my life to the villagers, so I couldn't leave," said Li.

Li said he hopes his 7-year-old daughter will also become a village doctor and urged more young people to serve patients in rural areas.

"It's not their fault. The younger generation is reluctant to work in the rural areas because of the poor conditions and pitiful salary. There is no insurance and they won't receive a pension," he said.

"I hope the problem will be solved as soon as possible so more doctors will be based in these areas and patients won't have to walk for hours to get treatment."

He Na contributed to this story.

(China Daily 01/09/2013 page6)