Not all people who die in times of famine die of hunger. Common illnesses such as diarrhoea, dysentery, fever and typhus claim many lives first. The precise impact of each disease in China at this time is extremely difficult to ascertain, not only because of the size of the country and the diversity of conditions on the ground, but also because some of the most problematic archives happen to belong to the health services. In a climate of fear in which millions of party members were purged or labelled as rightists, few subjects could be more sensitive than that of disease and death. When malnourishment reached the inner recesses of power in Zhongnanhai and Li Zhisui told the Chairman that hepatitis and oedema were everywhere, Mao quipped: ‘You doctors are just upsetting people by talking about disease. You’re making it difficult for everybody. I just don’t believe you.’1

Of course party officials continued to produce damning reports on all sorts of topics throughout the Great Leap Forward, often at great personal risk, but reliable surveys of medical conditions are hard to find. First the health services were battered by collectivisation, then they were overwhelmed by famine victims, and finally they simply collapsed. Hospitals, even in major cities, were stripped of resources, and by 1960 doctors and nurses were fighting for their own survival. In Nanjing, for instance, up to two-thirds of all nurses and doctors were sick. They were ill because the hospitals had become catalysts in the spread of disease and death. As one report indicated, flies and other vermin could ‘frequently’ be found in the food, causing diarrhoea among staff and patients. Even in top hospitals reserved for party members the heating had broken down, while staff wore dirty patches and rags stitched together. Few uniforms were ever laundered.2 In Wuhan severe shortages were compounded by criminal neglect, as most doctors and nurses in the People’s Hospitals seemed to lack what a report called a ‘sense of responsibility’. They turned a profit by diluting medicine with water. They stole from patients. They beat the sick. Male doctors abused female patients. Hospital finances were a shambles.3

In these conditions, it does not come as a surprise that few if any medical experts were inclined to spend time in famished villages armed with scalpels and test tubes, trying to establish the determinants of mortality. The countryside, where most of the people died, was cut adrift. When the extent of the famine was finally recognised in the winter of 1960–1, emergency centres were set up in abandoned cow sheds or disused farms to help the starving. In Rongxian county, Sichuan, those brought in were dumped on a thin layer of straw directly on the floor. There were no blankets despite the bitter cold. The stench was overwhelming. Pitiful moans of anguish echoed through the air. Some were left without water for days on end – not to mention food or medicine. In Tongliang the living shared beds with the dead; nobody seemed to care.4 In Guanxian things sometimes worked out the other way around: the living were locked up with the dead, as those in charge could not wait for some people to die. Yan Xishan, a mechanical worker suffering from epilepsy, was tied up and left to die in the morgue. Rats had already eaten the eyes and the noses of six cadavers in the room.5

One of the most striking features of the famine is the low incidence of epidemics. Typhus, also called gaol fever, hospital fever or famine fever, was mentioned, but did not seem to kill in large quantities. Transmitted in the faeces of lice or fleas, it appeared in crowded, unsanitary conditions, and was associated with famine, war and cold weather. It was common in detention centres for migrants fleeing the countryside, even in cities such as Beijing and Shanghai.6 Some 10–15 per cent of victims could succumb to typhus, typhoid and relapsing fever in times of famine, but this may not have been the case in China. Could the widespread use of DDT, efficient in pest control, have helped? This is not likely, given that other insects survived the onslaught of the country’s war against nature. As we have seen, locusts actually thrived in a distressed landscape, as did other pests. The rat population, which carried the flea, was culled by the campaigns of eradication launched at the beginning of the Great Leap Forward. But rats breed ferociously fast and are not fussy feeders.

A more convincing reason why typhus, with its rash and high fever ending in delirium, may not have been widespread is that epidemics were rapidly isolated. Here was a military regime which openly denied the existence of famine yet pounced on suspected outbreaks of infectious diseases. This happened, for instance, in the case of cholera, which appeared in Guangdong in the summer of 1961. The epidemic started in early June when several fishermen fell ill after eating contaminated seafood. Within a matter of weeks thousands more were infected, and soon well over a hundred people were dying of the disease. The local authorities used the army to impose a cordon sanitaire around the affected region. While the quarantine could not prevent cholera from spreading as far as Jiangmen and Zhongshan – panic even broke out in Yangjiang – the overall number of casualties remained low.7 Plague, too, spread to an area the size of a province in March 1960 but seems to have been contained.8

But other major epidemics that historians have come to associate with famine are also noticeable for their absence from the archives. There were higher incidences of smallpox, dysentery and cholera, but there is little archival evidence, so far, of millions being swept away by major epidemics. And the official gazetteers published decades after the famine by local party committees do not mention them frequently either. On the contrary, where disease is mentioned the set sentence is invariably that ‘deaths by oedema caused by inadequate nutrition were high’.9

The picture which emerges from the record is that of a country in the grip of a whole variety of diseases, rather than suffering from the impact of two or three epidemics historically associated with famine alone. And this wide-ranging increase was as much due to the destructive effects of collectivisation on virtually every aspect of daily life, from crowded kindergartens, filthy canteens and hazardous workshops to under-equipped, overcrowded and understaffed hospitals, as it was a consequence of widespread starvation per se. In Hunan some 7,500 children died of measles in 1958, twice as many as in the previous year, as families were forced to leave their offspring in congested kindergartens. Cases of polio were fifteen times higher in 1959 than in 1958. The incidence of meningitis doubled, attributable, again, to disastrous conditions in boarding kindergartens.10 Snippets of information from other regions confirm this trend. Thousands of cases of meningitis, for instance, also appeared in Nanjing in the winter of 1958–9, claiming 140 lives.11 The rate of diphtheria also increased hugely, causing seven times more deaths in Nanjing in 1959 than in the previous year.12

Hepatitis soared, but tended to affect privileged city residents rather than the impoverished masses in the countryside. In the cities of Hubei one in five suffered from the disease in 1961. In Wuhan alone some 270,000 out of 900,000 people tested positive.13 In Shanghai too the number of infections was high enough to prompt some state enterprises to request special medical facilities to treat the illness.14

Malaria was endemic. In the summer of 1960 up to a quarter of all villagers in parts of Wuxi suffered from the disease.15 Snail fever, or schistosomiasis, caused by a parasitic worm that attacks the blood and liver, was prevalent. There were thousands of cases in many a county in Hubei, where people came into contact with freshwater snails when wading barefoot through irrigated rice fields or when they went fishing. In Hanyang, hungry factory workers descended upon the many lakes surrounding the city to cut barley in the summer of 1961. Three thousand people were infected, a dozen died.16Hookworm, which sucks blood so voraciously that it leads to anaemia in the host, was common, even though reliable statistics remain elusive. But the problem was serious enough for the health authorities in Hunan to set a target of curing 3 million infected people in 1960 – in a mere eight counties.17

Everywhere the effects of collectivisation led to higher rates of illness. We have seen how people died from the heat of the backyard furnaces during the iron and steel campaign in 1958, but in the following years heatstroke continued to claim lives. Malnourished and exhausted workers were exposed to high temperatures all day long, and in Nanjing dozens of cases of heatstroke, several fatal, occurred in just two days in the summer of 1959.18 In Hubei even simple straw hats were lacking, but cultivators were compelled to work at noon in the blazing sun. Thousands suffered from the heat, some thirty cases being fatal.19

Even leprosy was on the increase. Caused by a bacterium that leaves permanent damage to the skin, nerves, limbs and eyes, it spread because of inadequate care, contaminated water and insufficient diet. Hospitals were creaking under the workload, turning away leprosy patients. In Nanjing some 250 cases were hospitalised, but lack of resources meant that they could not be segregated from other patients.20 Well over 2,000 lepers were known to exist in Wuhan, but a severe shortage of hospital beds condemned them to roam the city, scavenging for food.21 Lepers in the countryside could be less fortunate. In Qigong commune, Guangdong, a sixteen-year-old boy and an adult, both suffering from leprosy, were escorted up into the mountains and shot in the back of the head.22

Mental illness, however difficult to define, was widespread, no doubt because the incessant depredations of the state combined with widespread loss, pain and grief to drive famished people to insanity. Few meaningful studies were produced, but one Huazhou commune in Guangdong claimed that more than 500 villagers suffered from mental illness in 1959.23 In one curious case of mass hysteria, a third of some 600 students in a middle school in Rui’an county, Zhejiang, started crying and laughing without apparent reason in May 1960.24Similar reports came from Sichuan, where hundreds of villagers in several counties went berserk, talking gibberish and bursting out in convulsive laughter.25 One estimate placed the national rate of mental illness at one per thousand, but as the case of Huazhou shows many more people must have been unable to cope with the sheer violence of collectivisation and the horror of famine (that much is clear from very high rates of suicide, as we shall see in the next chapter). In any event, few were ever cared for, as the medical authorities had other priorities. In Wuhan, for instance, some 2,000 known cases had no access to specialist care, as a mere thirty beds were available for psychotic cases in the entire city.26

Even when they were badly treated, the mad had one advantage: like the court jester, they got away with telling the truth. As one survivor from the Xinyang region remembers, only one man dared to mention the famine in his village, walking around all day in a craze, repeating to all and sundry a popular jingle: ‘man eats man, dog eat dog, even rats are so hungry that they nibble away at stones’. Nobody ever bothered him.27

Major epidemics usually associated with famine did not afflict the countryside in China. Instead the destructive effects of collectivisation increased a whole range of illnesses, including poisoning, as people took to famine foods. Some could be quite nutritious – edible kelp eaten in Ireland during the potato famine of 1846–8, or tulip bulbs in the Netherlands during the hunger winter of 1944–5 – but many led to digestive diseases.

Even before people started scrounging for edible roots and wild herbs, digestive problems could appear, caused by severe imbalances in diet. Urban residents were sometimes given a much higher proportion of pickles, salted vegetables and fermented bean curd as substitutes for fresh greens. In Nanjing, for instance, many factory workers had a salt intake of thirty to fifty grams a day, almost ten times the amount that would be recommended today. They added soy sauce to hot water to break a monotonous diet. In one case a man was found to have ingested some five litres of soy sauce in less than a month.28But large amounts of leafy vegetables without sufficient carbohydrates also caused ill-health. When grain rations ran out by the end of the month and hungry people resorted to fresh produce instead, their skin would sometimes turn purple and they died, victims of phosphite poisoning. Dozens of fatal cases were reported in the countryside around Shanghai in 1961.29

Poor hygiene in the food industry caused diarrhoea outbreaks that claimed the weak and vulnerable. The chaos sown by collectivisation was felt at every level of the food-supply chain, as the state took command of production, storage, processing, distribution and catering. Food became just another output figure to be massaged, twisted and faked by factory bosses, while apathy, neglect and sabotage were common among workers. In Wuhan food poisoning was frequent in the summer of 1959, with hundreds of incidents being recorded every couple of days. Heat in the sweltering summer played a part, but a detailed investigation of six food producers identified widespread neglect as the main culprit. Flies were everywhere: one zealous inspector counted about twenty insects per square metre. Jugs and vats destined for the market had broken seals, their contents wriggling with worms. In one factory maggots were found in 40 tonnes of jam and maltose. Rotten eggs made their way into cakes and candies. There was no water on many of the premises, so workers did not wash their hands; some urinated on the floor. Once the foodstuffs reached the market, they rotted away in humid weather.30

A further problem was that many of the ingredients no longer came from the suburbs but were shipped over long distances instead. A batch of carrots from Zhejiang province, for instance, had rotted during transportation to Wuhan. And then the human and material tools for handling food were grossly inadequate. The pedlars who previously reached every corner of the market with fresh produce had been absorbed into a lumbering collective, while a sixth of all vegetables rotted in the streets simply because there were not enough bamboo baskets to distribute them.31

In the canteens the situation was no better. Flies were found in the food, while even basic utensils were missing. In one case 300 workers had to share thirty pairs of chopsticks during breakfast, which were rapidly rinsed in a washbasin filled with dirty water. Restaurants offered no escape from the cycle of neglect. The kitchens were described as chaotic, governed by flies rather than by people. When the flies were swatted they dropped into the food. In one eating place the vegetables were served covered in dirt. Insects were found in the vinegar and soy sauce containers.32

These examples are all from the cities – where people were relatively privileged in comparison to the abysmal conditions in the countryside. Since all the food was concentrated in large canteens, entire villages were affected by outbreaks of diarrhoea or food poisoning. In Jintang county, Sichuan, the thin gruel served to the 200 farmers in one canteen contained dozens of maggots. The reason was that the well used by the canteen was adjacent to a toilet, and drainage was poorly divided, in particular after heavy rain. Those who refused to eat the gruel went without any food for three days. The few who managed to down the concoction suffered from severe stomach pain. Dozens were taken ill. Ten died.33 Four vats with human excrement and urine, their contents spilling on to the floor, were found in a kitchen in Pengxian county. The water used to wash the food and dishes came from a stagnant pond by the doorstep. A quarter of the villagers were sick. Flies lorded it over people.34 In Jinyang, also in Sichuan, ‘chicken excrement is everywhere, human faeces have piled up, ditches are blocked and the stench is overwhelming’: local people referred to the canteen as ‘shit alley’.35 Even when there was food, canteens could run out of fuel or water. In Chengdu, where several branches of the Yangzi merged, some of the cooks had to travel half a mile to find water, and the grain was sometimes served raw.36 But in many cases, of course, the canteens did not operate at all. After they had run out of food and fuel, the doors were closed and villagers had to fend for themselves.

Collectivisation was chequered with accidents, as we have seen in the last chapter. People were not only given contaminated products or tainted food, they also fell victim to poisoning accidents. In less than a month in 1960 some 134 fatal cases were reported to the Ministry of Hygiene, although this was a pale reflection of the reality on the ground. Pesticides were sometimes stored in canteens and granaries, while the tools used to prepare food or handle chemicals were not always kept apart. In Baodi county, Hebei, a roller contaminated with pesticides was used to mill the grain, and over a hundred villagers were poisoned. Nothing was done, the flour was sold a few days later, and another 150 people fell ill. In Wenshui, Shanxi, a pot used for poison found its way into the kitchen of a kindergarten, where more than thirty children ended up with severe intestinal pains. In Hubei fertiliser balls were mistaken for bean cakes. A thousand people fell ill, and thirty-eight died.37

As food ran out, the government started promoting new food technologies and substitute foods. Most of these were quite harmless. The ‘double-steam method’, heralded as a ‘great revolution in cooking technology’, enjoined cooks to steam the rice twice, adding water each time to bulk up the food.38Some of the substitute foods consisted merely of ground corncobs, corn stalks or the chaff from soybeans and other grains. But the government also introduced new ersatz foods. Chlorella was heralded in the early 1950s by food experts around the world as a miracle form of algae that could convert twenty times more solar energy into protein than other plants. But the plankton soup that promised to pull millions out of hunger turned out to be impossible to produce and so vile to the palate that the craze eventually subsided. In China the watery slime was elevated to the status of miracle food during the famine. It could be cultivated and skimmed from swampy ponds, but more often than not it was grown in vats of human urine, the green stuff being scooped out, washed and cooked with rice.39 It probably contributed very little in terms of nutrition. Scientists discovered in the 1960s that the nutrients were encased in tough cell walls that were impossible for human digestion to break down.40

Prisoners were used as guinea pigs. Besides the green plankton, which sickened the inmates, they were also fed sawdust and wood pulp. Bao Ruowang – also known as Jean Pasqualini, the author of a memoir about life in a Chinese labour camp – remembered how brown sheets of the stuff were ground into paper pulp and mixed with flour. Mass constipation followed, killing the weaker prisoners.41 But even in the cities the spread of substitute foods caused obstruction of the bowels or rupture of the sphincter. Workers at the Liangma factory in Beijing had to prise out their faeces by hand.42

Villagers scoured the forest for plants, berries and nuts. They combed the hills for edible roots and wild grasses. In desperation, they scavenged for carrion, rummaged through rubbish, scraped the bark off trees and in the end turned to mud to fill their stomachs. Even in Beijing foreigners witnessed people knocking off the leaves of acacia trees with sticks, which were then collected in bags and turned into soup.43 Yan Shifu, a wiry man with a broad grin, was a young boy aged ten when the Great Leap Forward unfolded in Sichuan. He now works as a chef, and has a good memory for food. He recalls how ramie leaves were finely chopped and turned into pancakes, rape stalks were cooked into a thick stew, while mustard leaves were boiled. Pea stalks were milled, sieved and turned into small pancakes. Banana stalks were peeled and eaten raw, as if they were sugarcane. Radish was pickled and rare enough to be seen as a treat. Insects were popped live into the mouth, but worms and toads were grilled. Despite his family’s ingenuity, his father and his younger sister died of starvation.44

Some of the grasses, mushrooms and roots foraged by villagers were toxic. Few people actually knew what they were eating, as children were often the ones in charge of slipping out at night and foraging for wild herbs. ‘In those days,’ one survivor reminisced, ‘it was not possible to go out to look for known herbal remedies. We ate everything. We ate any plant that was green. We did not care, as long as we knew that the plant was not poisonous. We ate almost anything.’45 But accidents were common. In Hebei about a hundred deaths caused by contaminated food, diseased animals and toxic roots and herbs were reported each month.46 Cassava, a starchy tuber that could be milled into tapioca, is an excellent source of carbohydrates, but the leaves are highly toxic and cannot be eaten raw. In Guangxi province some 174 people died in a single month after eating it without proper soaking and cooking. A similar number in Fujian province succumbed to a paralytic neurological disease caused by cassava – among thousands of cases of food poisoning.47 Cocklebur, a weedy plant, was another hazard. The seeds were highly toxic, killing unsupervised pigs rooting for food. In humans it led to nausea and vomiting as well as twisting of the neck muscles, followed by a rapid pulse, breathing difficulties and eventually death. In ten days the toxic weed claimed 160 victims in Beijing.48

In a strange reversal of fortune, sometimes the most politically marginalised people were in a better position to survive, as they had developed coping mechanisms against starvation for many years before the Great Leap Forward. As the offspring of an ‘evil landlord’, Meng Xiaoli and his brother were chased from their ancestral house in Qianjiang, Hubei, immediately after the communist takeover in 1949. He was not given the time to gather any belongings. Though he was only a young boy, his jumper was torn from his back. They wandered about the village with their mother, ostracised by all, and ended up by the lakeside digging for wild vegetables. They slept on dried straw with the village dogs on their first night, and were later allocated a shabby mud hut. At first they tried to beg but nobody dared to give them any food. ‘So we tried to catch fish from the lake but couldn’t catch enough to eat because we didn’t have the right tools. But we still managed to survive because we could dig up lotus roots and pick up seeds. After a few months, my brother and I learned how to catch fish from the lake. Although we didn’t have any rice, in fact we could eat quite well.’ When the famine engulfed the village years later, the family was the only one to be prepared for survival.49

Straw and stalks were eaten from roofs. Zhao Xiaobai, the orphan girl aged eleven who had to work like an adult to look after her little sister, remembered how one day, tortured by hunger, she climbed up a ladder on to the roof. ‘I was still quite young then. I was very hungry, so I broke a piece of maize stalk [used to cover the roof] and began to chew it. It tasted delicious! I chewed one piece after another. I was so hungry that even maize stalks tasted good.’50 Leather was softened and eaten. Explained Zhu Erge, who witnessed half his village die of hunger in Sichuan but managed to survive because his mother was a cook in the canteen: ‘We soaked the leather chairs people used to sit on. After they were soaked, we cooked the leather and cut it into small pieces to eat.’51

Infected animals were eaten by the famished, even in the outskirts of the capital. In Huairou county, lambs contaminated with anthrax were regularly devoured by starved villagers.52 Hundreds were poisoned after eating bits of smelly fat mixed with clumps of hair, scraped off animal hides by a Chengdu leather factory, which were bartered for vegetables with a people’s canteen. Even the contaminated carcasses of diseased livestock, culled by a slaughterhouse in Guanxian county, were quietly sold to a local commune.53 When people were not eaten by rats, rats were eaten by people, dead ones sometimes being fished out of cesspits.54

When nothing else was left, people turned to a soft mud called Guanyin soil – named after the Goddess of Mercy. A work team sent by Li Jingquan was taken aback by what they saw in Liangxian county, Sichuan. It was a vision of hell, as serried ranks of ghostly villagers queued up in front of deep pits, their shrivelled bodies pouring with sweat under the glare of the sun, waiting for their turn to scramble down the hole and carve out a few handfuls of the porcelain-white mud. Children, their ribs starting through the skin, fainted from exhaustion, their grimy bodies looking like mud sculptures shadowing the earth. Old women in ragged clothes burned paper charms and bowed, hands folded, mumbling strange incantations. A quarter of a million tonnes were dug out by more than 10,000 people. In one village alone 214 families out of a total of 262 had eaten mud, several kilos per person. Some of the villagers filled their mouths with mud as they were digging in the pit. But most of them added water and kneaded the soil after mixing it with chaff, flowers and weeds, baking mud cakes that were filling, even if they provided little sustenance. Once eaten the soil acted like cement, drying out the stomach and absorbing all the moisture inside the intestinal tract. Defecation became impossible. In every village several people died a painful death, their colons blocked up with soil.55 In Henan, as He Guanghua recollected, so many people took to eating a local stone called yanglishi, which was ground and turned into cakes, that adults would help each other prise out their faeces with twigs.56 All over China, from Sichuan, Gansu and Anhui to Henan, people tormented by ravening hunger turned to mud.

People really did die of starvation – in contrast to many other famines where disease loomed large on the horizon of death. Starvation, in a strict clinical sense, means that the attrition of protein and fatty deposits in the body causes the muscles to waste away and eventually stop functioning, including the heart. Adults can survive for weeks without food, as long as they can drink water. The fat stored in the body provides the main source of energy and is broken down first. A small amount of calories are also stashed away in the liver as glycogen, which is generally converted within a day. But as soon as the fatty deposits have been exhausted, proteins are stripped from muscles and other tissues and used by the liver to produce sugars needed by the brain – the body’s first priority. The brain quite literally starts cannibalising the body, taking bits of this or that tissue to come up with the glucose it needs to survive. Blood pressure lowers, which means that the heart has to work harder. The body weakens and progressively becomes emaciated. As proteins are depleted, fluids start leaking out of the blood vessels and from disintegrating tissues, accumulating beneath the skin and in cavities around the body, producing oedema. The swelling first appears in the face, the feet and the legs, but fluids can also gravitate around the stomach and chest. Swollen knees make walking painful. Taking extra salt or watering down a meal to make it last longer only worsens the condition. But some of the starving do not suffer from oedema and dehydrate instead, their skin turning to parchment, shrivelled and scaly, sometimes covered with brown spots. As the throat muscles weaken and the larynx dries up, the voice grows hoarse before falling silent. People tend to curl up to save energy. The lungs weaken. The face caves in, cheekbones stand out and bulging eyeballs are a gruesome white, staring vacantly and seemingly without emotion. The ribs poke through the skin, which hangs in folds. Arms and legs look like twigs. Black hair loses its colour and falls out. The heart has to work harder still, as the volume of blood actually increases relative to a declining body weight. In the end the organs are so damaged that they fail.57

Starvation may have been a taboo topic, but the archives are replete with reports about oedema (shuizhongbing) and death by starvation (esi). Wu Ningkun, a professor of English literature, described what happened as he went through hunger: ‘I was the first to come down with a serious case of oedema. I became emaciated, my ankles swelled, and my legs got so weak that I often fell while walking to the fields for forced labor. I did not know what I looked like, as there were no mirrors around, but I could tell from the ghastly looks of the other inmates that I must have been quite a sight.’58 Few victims were as eloquent, but the symptoms were observed everywhere. In a commune in Qingyuan – once considered Guangdong’s granary – 40 per cent of the villagers suffered from oedema in 1960.59 Even in cities it was common. We have already seen how half the workforce suffered from oedema in Beijing. Among high school students in Shanghai oedema spread in 1960–1.60 In Nankai University, Tianjin’s top institution of higher learning, one in five suffered from oedema.61 So common was the disease that when the famished did not develop it, an explanation was warranted. Hu Kaiming, an outspoken official appointed as the first secretary of Zhangjiakou in 1959, observed how in the winter of 1960–1 starving villagers would suddenly drop dead as a consequence of low blood sugar, without the usual signs of oedema.62

Why did villagers not succumb to epidemics in much greater numbers before terminal starvation set in? One reason, suggested above, is that the party closely monitored infectious diseases. But collectivisation also brought about organisational chaos and the collapse of rural health care, which was rudimentary in the best of cases. A more plausible explanation is that people in the countryside starved to death much more quickly than elsewhere, reducing the window of opportunity during which germs could prey on a lowered immunity. The only available food was in the collective canteens, and access to these was controlled by local cadres. Under immense pressure to come up with tangible results, many local officials used food as a weapon. As we shall see in the chapter on violence, villagers who did not work were not given any food. And those who could no longer work were often exhausted. Death followed promptly.

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