The richest man in one of the poorest villages in China is the "barefoot doctor" Hua Wanxiang, who sells cigarettes, beer and antibiotics.
Although he lives in Jinhua - a remote community deep in the hills of Guizhou province - Hua has made his money by moving with the times.
In the communist past, offering rudimentary treatment to the sick would have been enough for the village doctor to secure his status in Jinhua.
But in the capitalist present, money determines social rank. This helps to explain why the village doctor recently padlocked his old clinic shut and opened a shop next door selling groceries alongside medicine.
It was an easy move. The only medical equipment he owns is a stethoscope, some tweezers and a sterilising bowl. He can now sell tobacco while referring locals to hospital for lung diseases; flog crates of beer one day and painkillers the next.
This shift from public service to market principles is entirely in keeping with the wider transformation of healthcare in China, which is now among the most market-driven in the world.
Like the entire economy, the system has a lot more money than 20 years ago, but far more inequality. It is a source of embarrassment for the communist party and a cause of unrest in the provinces.
In no other sector of society has the difference between urban rich and rural poor become so apparent.
Compared to the commercial capital of Shanghai, Guizhou's 37 million people - most of who are peasants - can expect to live 13 years less, mothers have a 10 times greater risk of dying during childbirth, and infants are five times more likely to perish before the age of five.
For those who survive, illness is as much a financial as a physical threat. Get sick in the countryside, where there has been no health insurance system for most of the last 20 years, and the entire family can be ruined for generations.
Surveys suggest that health problems account for between a third and a half of all cases of destitution. The health ministry says three-quarters of the rural patients who declined to undergo recommended hospital treatment did so because they could not afford it.
In Jianghua - where peasants are fortunate if they earn £20 a month - officials say the rate is likely to be even higher.
"I guess about 50% of the 11,000 people in this district can afford to see a doctor and only 10% would be able to pay for surgery that cost more than 1,000 yuan [£66]," says Bai Xiuhau, the deputy director of the district government.
"Some people can't afford treatment. They borrow and pay for as much as they can. But if they run out of money before they are cured, then they just have to go home and die."
A peasant saying has it that a pig must be taken to market every time an ambulance siren wails, a year's work is ruined as soon as you sleep in a hospital bed, and if you are struck with a serious disease, 10 years of savings go up in smoke.
For Mo Wangfa, the cost of contracting spinal tuberculosis has been even higher. Since 1999, the farmer has spent more than 10,000 yuan on check-ups and treatment. With no support from the government and no insurance, he had to borrow most the money, much of it from loan sharks who charge 6% interest.
What passes for family treasures now are his x-ray charts and medical reports, all of which cost far more than he could ever earn. He is still too sick to work his fields.
"Before the illness, I was doing reasonably well. I wasn't rich, but I wasn't poor. Now I have big debts," he says. "I plan to ask my children to go the cities to find work so we can pay back the money."
Aside from compassion, doctors have few incentives to reduce costs or pursue long-term public health goals. In some areas, tuberculosis and other preventable diseases are making a comeback because vaccination programmes are under-funded.
Meanwhile, the privatisation of medicine is blamed for the rampant over-prescription of drugs, which has created new strains of TB and other diseases that are resistant to antibiotics.
"I prescribe penicillin more than any other drug," says Hua, who charges 2 yuan for each injection. "I mostly recommend it for rheumatoid arthiritis. A lot of villagers suffer from that."
Few physicians in the west would recommend penicillin for this ailment, but it is not unusual for village doctors to assume antibiotics are a panacea for everything.
With two years training and no salary, Hua is at the bottom of a healthcare system that that must provide screening, education, and treatment for the biggest population on the planet.
In the 1960s, the government raised an army of paramedics, who were given basic training in western disease control and traditional Taoist medicine.
While opinions vary about the medical worth of these "barefoot doctors" - so called because some were so poor they walked from village to village without shoes - they are credited with having an important role in educating people in the basics of hygiene and infectious disease control.
Partly as a result, the health of China's rural population was once one of the proudest boasts of the communist party. Government figures suggest life expectancy jumped from 35 to 65 years in the three decades after Mao Zedong took power in 1949.
During the same period there were substantial declines in recorded cases of tuberculosis, hepatitis B, and schistosomiasis, as well as improvements in infant mortality.
Most of these gains, however, have levelled off since 1978, when rural cooperatives - which organised health insurance - were abolished, and doctors and health authorities were encouraged to find private sources of income.
In the past 25 years, the share of medical spending borne by individuals has jumped from 20% to 60%.
Although government healthcare spending has risen steadily from 3.7 trillion yuan in 1998 to 7.5 trillion yuan in 2004, the funds have been disproportionately invested in cities and high-tech equipment.
According to one study, the rural share of medical expenses dropped from 34·3% to 22·5% in the decade up to 2003. Yet more than half of China's 1.3 billion population live in the countryside.
China's main health indices continue to be reasonably good given the country's stage of economic development and they are excellent compared to Russia, which saw life-expectancy fall by more than 10 years after the fall of the Soviet Union. In terms of the number of doctors and hospital beds, China scores well.
But such gains mask huge gaps. Medical care in Shanghai is now on a par with that of the west. Doctors in the city are well trained, well paid and the high-end healthcare market has expanded to the point where a private "five-star" maternity clinic opened last year charging £660 a night for a suite with a karaoke bar.
That is more than double the annual income of Huang Bin, the most qualified doctor in Dayin district, which covers Jinhua village. Typical of China's emphasis on hardware rather than software, the government recently constructed a new hospital in the district, but there are no funds for medical staff.
Huang's only source of income is drugs sales. Even though he is under pressure to prescribe as much medication as possible, people in this district are so poor that he usually makes no more than a few hundred yuan a month.
"I'm thinking of going back to farming or perhaps doing construction work in the city," he says. "It may be a waste of my skills, but it can't be helped. It is very hard to make a living as a doctor in a place like this."
Nationwide, drug sales now account for half of hospital incomes, which has led to suspicions of overprescribing.
Half the babies born in China are delivered by caesarean section, partly because doctors make more money they way.
And China is one of the few countries in the world with more doctors than nurses, despite research suggesting nurses provide more cost-efficient services.
Public resentment is rising. According to the state-run media, 5,500 medical workers were injured last year in assaults causing more than 200m yuan of damage. Among the biggest disturbances was a riot by 2,000 protesters in Guangan, Sichuan province, last November that was sparked by rumours that a young boy was denied life-saving treatment because his guardians could not afford the £50 treatment fee.
Earlier this year, the government announced that it would deploy police and private guards in hospital wards.
Security is not the only concern. The World Health Organisation has monitored the decline in access with alarm. In a comparison of health systems in 2000, China was ranked a miserable 144th out of 191 states. In terms of access to medical care, it was fourth from bottom - beating only Sierra Leone, Brazil, and Myanmar.
The effect of these inequalities is increasingly apparent. An estimated one in ten of the 1·3 billion population is thought to be a carrier of hepatitis B. Syphilis, rabies and drug resistant tuberculosis, all under control 20 years ago, are sharply on the rise again.
New concerns - such as Sars, Bird Flu and HIV/Aids - have pushed the health issue high up the political agenda and beyond China's borders.
WHO, the World Bank, and the Organisation for Economic Cooperation and Development are now preaching socialist values - less market, more state intervention - to the communist government in Beijing.
"The heavy reliance on market forces during the past two decades has bought wild capitalism to China's health system. Hospitals operate in an unrestrained way," says Hana Brixi of the World Health Organisation.
The central government is aware of the problem. A public thinktank last year issued a damning report on the current state of the system. A major shake-up is being planned.
Since last year, the central government has boosted the share of spending on rural healthcare and introduced a medical insurance scheme for farmers.
It is an improvement on nothing, but the effect has been limited. The scheme only covers inpatient care and works through reimbursement. This means poor peasants still struggle to find the initial fee for treatment. The diversity, inequality and scale of China ensure there will be no simple solution to the country's health challenges. But the reforms currently under consideration look likely to emphasise that it is the responsibility of the government - not just the market - to ensure universal access to essential healthcare.
Explainer: China's causes for concern
The barefoot doctors of Chairman Mao and some of the triumphs of Chinese traditional medicine - such as the discovery and use of artimisinin, which is now the developing world's best hope against malaria - may have done much for China's reputation in healthcare. Sars, on the other hand, did it significant damage.
China's failure to share with the UK and the rest of the world the scale of viral infection and to take urgent action to confine it disturbed the public health community. The first case occurred in Guandong province in November 2002. In February 2003, the Chinese ministry of health reported there had been 300 cases, including 5 deaths. In March, the World Health Organisation declared that severe acute respiratory syndrome (Sars) was a global threat and cases were identified in the UK, as in many other countries worldwide.
Sars demonstrated more clearly than any other epidemic has done that disease is now a global problem. They can move around the world faster than ever before on aircraft. So there is concern here about the renewed spread of preventable diseases in China, such as tuberculosis, and particular anxiety about the apparently extravagant use of drugs.
Here in the UK, various campaigns have urged doctors not to use antibiotics against viral colds and coughs - they only work against bacteria. But in China, as in much of the developing world, there is huge overuse of antibiotics, with the likely result that organisms will become resistant and the life-saving drugs will cease to work. When the resistant organisms are spread around the globe, they become a problem for us all. Multi- and extreme-drug resistant forms of tuberculosis have now been identified on every continent.
China's healthcare problems have much to do with the arrival of the free market. At one end of the scale, it has doctors as skilled as anywhere in the world. At the other end, it has people dying because they cannot afford treatment. Sarah Boseley
