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Home to 1.29 billion people, China is the most populous nation on earth. Spanning 3.7 million square miles, it is not one world, but many, its vast expanse made up of mountains and coastline, farmland and desert. Like the landscape, China's health problems are anything but uniform, says native son Yuanli Liu. In the coastal regions, which are the most developed, chronic conditions like cardiovascular disease prevail. The western regions, by far the poorest, suffer most from communicable diseases and malnutrition. The middle regions share a mix of these problems.

When Liu left his homeland in 1987 to study health policy in the U.S., it was the rural poor whose plight burned in his memory--and fueled his desire to champion health care as a basic right within China and globally.

Liu could not forget the mountain people, who shared their shelter with military families like his. Liu's father, an army physician, cared for the peasants as well as soldiers. "As a child I would assist my father as a kind of bedside nurse," Liu says. "Many people suffered from weird diseases, including goiter, caused by iodine deficiency. Years later I would still be moved by the thought of their gifts, which often consisted of the feast they had saved for a special occasion--eggs and rice."

If Liu's work has one defining theme, it is equity, or fairness, in health systems. His interests include documenting inequalities in health; understanding social and economic determinants of health disparities; and finding solutions to these problems. "It is not enough for me to publish papers," says Liu, 43, who joined the HSPH faculty in 2000. "In China, one of my major goals is to help the government create health-insurance programs for the hundreds of millions who have none."

The People's Republic of China was founded upon egalitarian principles. For decades, rural health care was provided through a community-based, cooperative system administered through the "people's communes." In the wake of the government's move in the 1980s to a market-driven economy, this system collapsed, leaving 800 million people without a safety net.

In 1994, Liu and HSPH's William Hsiao began documenting health and health-system problems in 114 rural counties. In 10 they piloted a community-financed insurance system and found that poor areas could not support it on their own. "One flood or drought would wipe them out," Liu says. "The government had to step in."

In 2001, officials commissioned from Liu a study that drew on national survey data. Liu hoped they would take action after his findings revealed the dire economic consequences of what he calls "medical impoverishment." Liu showed that medical expenses increased poverty in rural areas by 44 percent, reflecting "the crucial link between economic growth and health." Skeptical, government officials went into the field, where they heard more horror stories. "Seeing how one episode of illness could bankrupt a family," Liu says, "they began to accept the idea of government-sponsored insurance."

Developing a rural health insurance system for China requires, in Liu's words, "three models for three worlds"--the coastline, middle, and western populations. Liu proposed varying levels of governmental support for each, with a matching-fund-financed insurance system for the rural majority. In 2002, the government embraced his proposals. Since then, Liu has helped design and pilot a Medicaid system for China's urban poor, including migrant workers and the unemployed.

Liu's work has had global impact. When the United Nations set up task forces to advise countries on how to achieve the Millennium Development Goals by 2015, Liu was invited to join the committee on controlling infectious diseases and broadening access to essential medicines. His proposed strategy for defining and measuring access to those medicines was quickly adopted. As a member of the Global Health Equity Initiative and the Global Equity Gauge Alliance, Liu also has helped set benchmarks for narrowing health disparities in 11 nations.

Nurturing trusting relationships with the Chinese is just one hallmark of Liu's effectiveness, his colleagues say. William Hsiao asserts that Liu is "able to see and grasp important, complex problems in public health long before others do.
"In his efforts to bring basic care to millions of people," Hsiao adds, "Yuanli is also able to communicate his deep passion. This, too, is his gift."

NEXT: HEATHER NELSON

Photo: Kent Dayton