The road is narrow and choked with mud, as it winds through this rural township in China’s impoverished southern highlands and up to the weather-beaten doorway of an aging hut made of earth and straw.

Inside the one-room hovel, near the beckoning warmth of an open fire, Li Fa-fa sits on a dirt floor hardened by use and hunches over a pair of spindly legs twisted and gnarled to near uselessness by an unseen tormentor deep in his bones.

“When I was small, I was very lively, very naughty,” recalled Li, 38, looking back on a childhood spent running and jumping with other boys across the buckwheat and maize fields that grudgingly give up the meager staples of life here in Guizhou province, one of China’s poorest regions. He gazes vacantly toward the bed and the faded patchwork quilt he shares with his mother. “Now,” Li said, “there is nothing for me to hope for.”

Li is one of at least 20 million Chinese suffering from fluorosis, an often debilitating disease caused by the buildup of heavy concentrations of fluoride in the teeth and bones.

The source of Li’s malady is no mystery. In fact, it’s as near as the brick and clay pit that doubles as both his hearth and stove and burns, night and day, the cheap but fluoride-rich coal of local mines.

Like his parents before him and his grandmother before that, Li suffers the afflictions of fluorosis – symptoms of which began surfacing when he was 12 and have since left him crippled – because he can’t afford alternative fuels in this wood-scarce region, where most people scrape by on the equivalent of a dollar a day or less. Li depends on government assistance.

“Fluorosis is a disease closely related to poverty,” explained Yang Da-quan, 60, an expert on the illness and director of research for the Regional Public Health and Anti-Epidemic Station in Guizhou. “When people are still struggling to satisfy their basic needs – food, clothing and shelter – they have no time to care about the disease, let alone have money for treatment.”

Across much of rural China, in millions of poor households like Li’s, unpure coal burns in open stoves, often with no chimney or vent to expel the fluoride-laden smoke. It remains trapped in the home for residents to breathe, or settles into food.

“This is the major reason that residents suffer from fluorosis,” concludes a recent report by the Chinese Ministry of Health, which called the problem “severe and widespread.” It is not fatal, though.

Guizhou has far more victims of fluorosis than any other province in China, followed by Yunnan, Sichuan and Hunan provinces, according to the report.

A quarter mile down the road from Li, 47-year-old Xu Chao-xiu is a prisoner of her bed. Fluorosis began to attack her body nearly 20 years ago, forcing her to stop working in the fields near her village. About five years ago, she could no longer bend her knees or turn her head. Now she can no longer sit up, shrinking beneath a dirty quilt in a dark room. Her children must feed her.

Xu’s 12-year-old daughter, the oldest of three, had to quit school to care for her mother. The family has an annual income of $ 20, cultivating a small plot of land for food. “We thought I had arthritis, because it’s so cold and wet here in winter,” Xu said. “Who knows what this fluorosis is.” Now, her daughter cares for the family, continuing to cook corn meal or potatoes over the open fire stove that has poisoned her mother.

The health ministry, which turned down repeated requests for interviews, has long recognized the link between burning heavily fluoridated coal and the ills of fluorosis. Chinese scientists have been writing about the disease and its root causes for more than a decade, and three years ago the Health Ministry co-hosted an international conference on the subject in Beijing.

Dental fluorosis is not unique to China, though the problem has been addressed in most modern countries.

Among the earliest documented outbreaks was in Italy around the turn of the century, and, by 1910, in the southwestern United States, said Gary Whitford, a specialist on fluorosis who teaches dentistry at the Medical College of Georgia in Augusta.

The more serious skeletal fluorosis, however, is rare outside of China and some parts of Pakistan and northern India, where drinking water can contain high levels of fluoride, a natural element that does not break down and is present in varying levels virtually everywhere.

“It’s in all living tissues and all inanimate objects,” said Whitford. “It’s everywhere, but normally the concentrations of this natural element are very low.”

In fact, very low levels of fluoride are added to the drinking water of many areas of the U.S., as a way to reduce dental decay. Those levels are far below what would be required to cause fluorosis.

There have been only five cases of dental fluorosis documented in the U.S. this century, and no cases of the more serious skeletal fluorosis.

In China, government-supported programs have provided cleaner-burning stoves for more than 1.3 million rural households, under an initiative the communist government seeks to expand. The government has launched a comprehensive campaign aimed at reducing the consumption of high-fluoride coal, developing new ways to protect crops and foods from fluoridated smoke and seeking international assistance to address the problem.

Fluorosis remains widespread across China, though, because it’s interwoven with the broader development challenges faced by a country whose rapid urban growth has yet to be mirrored in the countryside.

“They have identified the problem, but the issues are related to poverty,” said Janet Hohnen, senior public health specialist at the World Bank, the world’s largest development organization. “Ill health leads to poverty, and poverty leads to ill health.”

The World Bank helped fund the first comprehensive study of fluorosis in China some 15 years ago by the Chinese Academy of Preventive Medicine.

Similar studies have continued. In 1995, China’s Ministry of Health documented 18.2 million cases of dental fluorosis – which can cause severe pitting, discoloration or loss of teeth – and another 1.5 million instances of the far more serious skeletal fluorosis, which can weaken, make brittle and distort bones.

Those numbers, moreover, are likely low, as medical statistics are far from complete across China’s vast rural areas, where six births in 10 still take place without a doctor or nurse in attendance.

Beijing has begun to connect the political dots between fluoride problems and the widening gulf between China’s urban economic boom and its continuing rural poverty.

Despite economic growth averaging near 10 percent a year for the past decade, a growing divide between rich and poor is seen as a potentially explosive problem. Beijing is struggling to address simmering unrest across much of the countryside, where hundreds of millions have been left behind by the economic gains that have changed life dramatically for a Chinese middle class of perhaps 100 million people.

The State Council, the rough equivalent of a cabinet, held a National Health Conference last December, deciding, among other things, that rural health problems like fluorosis were impeding development in the hinterlands. One result: Money spent to address fluorosis is also regarded as an investment in development.

“It’s a new emphasis, and this (fluorosis) is the sort of thing they are looking at,” Hohnen said from her office at World Bank headquarters in Washington, D.C. “Besides any investment in obvious economic development, investment in alternative fuel sources or protection of families from the smoke will contribute to the anti-poverty drive.”

It is a daunting challenge – to change the living and working patterns of China’s poorest regions. The coal pits are the peasants’ source of income, heat and fuel. At one pit that supplies about 40 tons of coal a day in the Guizhou province, 28-year-old Chen Gu-xue talks of his hard work. He smiles, revealing teeth broken and turned a dark brown by severe fluorosis.

Each day the young man makes 15 trips into the dark pit, pulling short, heavy carts loaded with coal. His face is black with coal dust. “People die here all the time. I am very careful,” he says proudly. “I am very lucky, too.” After this long day’s works, he will bring home a little more than $ 3.

Fluorosis is just one of the health problems of epic proportions that confronts China’s 1.2 billion people, with a per capita income of roughly $ 700 a year.

The country had 1.04 million documented cases of infectious, and potentially lethal, tuberculosis, for example, as of last March, according to the World Health Organization, and millions more suffer from a range of respiratory infections that also can be fatal.

By devoting scarce resources to addressing its most critical health problems, China has made some remarkable gains.

It hasn’t had a confirmed case of polio, for instance, in 2 1/2 years, a major achievement echoed by great strides against malaria, leprosy and other scourges the Chinese have battled for centuries.

And with development, China is being pressed to deal with new headaches – increased lung and heart disease associated with upticks in cigarette smoking, for example.

Fluorosis stands out as a lingering problem that requires no new medical findings nor expensive medicines to overcome.

The day that happens, however, remains far away.

“It will take a long time,” said Yang, the Guizhou researcher. “I am not sure if I can live that long to see this disaster go.”

Bob Deans reported from Beijing and Washington and Liu Xin from Zhijin for this story.
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Fluorosis in China

A 1995 survey found fluorosis in 201 counties in 13 Chinese provinces among a population of 31 million and 1.5 million cases of skeletal fluorosis.

Highest incidence is in Guizhou province, with a reported 10.3 million cases of dental fluorosis out of a population of 14 million. Most occur in the province’s east and southeast regions.
How it affects teeth

Normal teeth are formed when cells (called ameloblasts) secrete proteins that collect calcium and phosphate to form enamel, the hard, smooth shell. Enamel protects the tooth’s basic structure, the dentin.

Heavy doses of fuoride in childhood leave abnormally high levels of protein in tooth enamel, like dust on the surface of paint. This leaves holes in the enamel, letting water, food and saliva reach dentin. That leads to discoloration and erosion.
How it affects bones

Normal bone is formed when cells (called osteoblasts) secret proteins that then collect calcium and phosphate.

High levels of fluoride cause too many of the cells to form. That can lead to thickened bones, irregular surfaces and even tiny spikes on normally smooth bone. In severe cases, bones become distorted.

In advanced cases, ligaments take on bone matter, growing hard. That leads to stiffness and pain in joints and sometimes in the spine.
Sources: National Office for Endemic Disease Control, Ministry of Health, People’s Republic of China and Dr. Gary Whitford, University of Georgia.