Rochester Studies in Medical History. Rochester, NY: University of Rochester Press; Woodbridge, UK: Boydell & Brewer, 2012. xii, 294 pp. (Figures, tables, maps.) US$90.00, cloth. ISBN 978-1-58046-433-8.
Since the late nineteenth century, states have increasingly taken it upon themselves to provide basic health care for their populations, but this goal has often been thwarted by limited finances and personnel. With up to 90 percent of China’s 1949 population living in rural areas, the question for the state was how to spread resources in an effective, yet efficient manner. A tiny group of elite Western-trained physicians tried to implement rural medicine before and after 1949, yet even sixteen years after Liberation, Mao Zedong famously accused the Ministry of Health of serving only privileged, urban party elites. As Xiaoping Fang tells us in his important monograph, free services for civil servants made up 33 to 73 percent of total health-care expenditures between 1955 and 1965 in a single county, despite covering only 2 percent of the population (29). The barefoot doctor movement of the Cultural Revolution saw the first sustained penetration of the countryside by state medicine, and Fang’s book analyzes the movement through extensive interviews and documentary research. If official propaganda proclaimed that the barefoot doctors primarily brought herbal medicines to the doors of Chinese villagers, Fang demonstrates the opposite—it was Western medicine and mass-produced pharmaceuticals that these paramedical professionals promoted. The barefoot doctor program of 1968 to 1983 was “a pivotal stage in the displacement of Chinese medicine by Western medicine in rural China” (181).
From 1949, Chen Hongting and his Jiang village clinic become the reader’s interlocutors to explore these revolutionary changes to the medical field in rural China. In chapter 1, Fang demonstrates the plural medical ecology in rural China that included family businesses of Chinese medicine like Chen’s, but also folk healers, bonesetters and religious healers. In 1952, Chen and other medical practitioners formed a union clinic that was responsible for doing public health work, but with no funding. These union clinics “represented a significant downward extension of the state medical system” (27). But a comprehensive system based in Western medicine was not introduced to the countryside until the Cultural Revolution.
In the late 1960s, Chen Hongting and his colleagues began to introduce Western medicine and spread the barefoot movement (chapter 2). To one prospective disciple he said: “I find you clever and good at studying. I choose you to be a barefoot doctor. I will come to stay at your home. You will study under me” (48). These doctors were mostly young, between 17 and 26 years old, often semi-literate. The movement notably expanded medical work to include women in a significant way. For the first time in rural China, a standardized system of medicine was spread through a corpus of textbooks and journals, many of them well illustrated. These included the Manual for Barefoot Doctors. Contrary to common belief, the book is not primarily about herbal medicine, but is one-third about public health, epidemic prevention, first aid, family planning, basic surgical skills and human anatomy. The remaining two-thirds is therapies using a combination of herbs and Western drugs. Basic Western medical technology in the form of blood pressure metres, thermometres and stethoscopes, along with IUDs were spread widely, along with basic operational skills that included injections, disinfections and intravenous drips. Why did they focus on Western medicine? Chinese medicine was too difficult. Barefoot doctors studied on average only two to four months, although some studied up to one year, and this was not long enough to learn the classical Chinese necessary to read Chinese medical classics.
Chapter 3 describes how the early PRC saw medicine shops folded into the union clinics, the end of the division of doctors and pharmacies that had existed for thousands of years (75). Yet Western medicines were completely out of reach: a single bottle of basic antibiotics cost three years’ salary for a villager in 1957. A proclamation by Chairman Mao in 1969 saw pharmaceutical prices reduced and standardized nationwide on over 1200 basic drugs so that prices in 1971 were one-fifth that of 1949 (78). This massive state intervention saw a complete turning point in reducing mortality from infectious diseases by 1970. Mortality for measles dropped from 22 to 4 per hundred thousand and fatalities from 2 percent to 0.46 percent. Chapter 4 demonstrates how Western medicine continued to triumph over Chinese medicine in propaganda films of the barefoot doctor movement, although there was a resurgence of emphasizing use of local herbs when state expenses grew too fast in the 1970s. Nonetheless, the success of Western drugs was so significant that it led as early as 1978 to the over-prescription of Western medicine among barefoot doctors (121).
As the movement spread, it began to create increasingly institutional spaces that governed the medical encounter (chapter 5). Fang describes how the three-tier system of brigade, commune clinics and county-level institutions of the early PRC was transformed by the barefoot doctor movement to a dumbbell-shaped structure as the middle commune level (now township) became increasingly redundant (145). By developing brigade-level (now village) medical service at villagers’ bedsides, barefoot doctors undercut the role of commune clinics as patients would go straight to county hospitals for specialist care. Once established, barefoot doctors became increasingly professionalized (chapter 6) and survived as a class into the reform era, but lost their official title in 1985 to become either more highly qualified “village doctors,” or merely “health workers” (175).
Fang Xiaoping’s book demonstrates that the very success of the barefoot doctor movement at bringing state medicine and its public health benefits to the countryside had two interrelated effects, the marginalization of Chinese medicine and the overuse of Western drugs and technology. This book will be of wide interest to anyone wishing to understand the state of health care in China today and the roots of its successes and dilemmas.
David Luesink
University of Pittsburgh, Pittsburgh, USA
pp. 584-586