The Barefoot Doctor

The barefoot doctors of China were cultural heroes, both at home and to an anti-establishment sector of the West. But to some, they were just practicing traditional Chinese medicine, making them more useful for propaganda posters than for public health. The truth is that the barefoot doctors were of great practical benefit and were the avant–garde  of modern medicine in China. 

 Contemporary Poster

Contemporary Poster

Down on the Farm

Western readers will need to get over some ‘red-scare’ bias here in recognizing that Chairman Mao Zedong was a practical leader. But even the top-down government of Communist China was having a hard time getting formally trained physicians to take up practice in the countryside, where the peasants of the agricultural revolution needed hands–on care. The solution was knowledge transfer. 

Working rice paddies was done barefoot, a significant health hazard. In 1965, Mao, the son of a (wealthy) farmer announced plans to build upon a nascent program and formed the Rural Cooperative Medical System. It was designed to counter-balance the existing urban-centric Ministry of Health services staffed by mostly Western-trained doctors. 

Knowledge Transfer

Consistent with the ethos of ‘the cultural revolution’ many of these urban doctors were recruited for rural service, but for a limited time and in a training and supervisory role. Their student body were villagers who had graduated secondary school and undertook a variable number of months of on-the-job training. Often lost in modern accounts is the fact that the barefoot doctors were instructed in modern medicine. Their ‘black bag’ had not only the traditional artifacts of acupuncture, moxibustion and herbs but also ‘drugs’ and a guide to ‘best-practices’—the Barefoot Doctors manual

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By the 1960s ninety percent of villages had a resident ‘health-care-provider,' who were both selected and paid for by the village. The program brought down costs and expanded preventative care. Schistosomiasis infection came under control. Between 1950 and 1980  infant mortality declined dramatically and life–expectancy increased . At the 1978 International Conference on Primary Health Care, Dr. Margaret Chan, Director-General of WHO, gave a keynote address praising China’s public health initiatives. 

Long before the West had Nurse Practitioners and Physician Assistants, China had Barefoot Doctors. By the time the program ended, in 1981, with the end of agricultural communes, it had given way to a cadre of physicians who started as barefoot doctors.

Legacy

One of these, Chen Zhu, was a barefoot doctor for five years. He went on to get a master’s degree in China, PhD and MD degrees in France, become a foreign member of the prestigious United States National Academy of Science, French Academy of Science, The Royal Academy,  winner of the Szent-Gyorgyi Prize for Progress in Cancer Research, President of the Red Cross Society of China, China’s Minister of Health, and, oh yes, Chairman of the Chinese Peasants’ and Workers’ Democratic Party. Many other barefoot doctors eventually became physicians, enough to serve two-thirds of China’s villages. 

 Dr. Zhu with Secretary Sibellius in 2011

Dr. Zhu with Secretary Sibellius in 2011

The Manual

The Barefoot Doctors Manual is readily available. It is more than a good first aide book but less than the Merck Manual. Some early editions in English translation left out the abundant sections on Western medicine, leaving a false impression on the hippie generation that traditional Chinese medicine was sufficient, even preferable. This notion debunked by the famous sceptic Brian Dunning. To the contrary, as discussed in Lancet:

“Rather than herbs and acupuncture, antibiotics and western medicines were prescribed and even simple surgical operations commonly done. Thus the arrangement solved the distribution of health-care resources under the urban–rural dual-economic system, and played an important part in modernizing health care in rural China.”

In the complete editions we have much anatomy and nosology of medicine. The section on burns includes modern features such as surface maps and category by degree. One could give herbs and/or demerol, and the importance of fluid balance and infection is emphasized. For headaches there is an extensive differential diagnosis, including iridocyclitis. Treatments options include acupuncture, massage, chrysanthemum  flowers, aspirin and phenergan. Attention is paid to healthy pregnancy and there is much discussion of infectious disease prevention. 

Schistosomiasis in particular was prevalent—barefoot in the rice paddies. It is caused by a worm transmitted from snails. It was called ‘big-belly’ by the peasants, 10 million of whom were affected at one point . A campaign to control schistosomiasis was so successful that the Communist Party said it had turned ‘snail-infected swamps into rivers of happiness’.

 'Big Belly' in Schistosomiasis

'Big Belly' in Schistosomiasis

 Schistosomes

Schistosomes

 China, US and Europe have comparably low rates of mortality from schistosomiasis

China, US and Europe have comparably low rates of mortality from schistosomiasis

Cautionary Tale

In 2002 China reincarnated a rural health program as the New Rural Medical Cooperative Scheme. It deals with, oddly enough politically speaking, the problems of income disparity and insurance coverage. These were not the problems at the height of the barefoot doctor era, which brought public health advances the whole nation.

 Chinese healthcare stamp

Chinese healthcare stamp

Listen to what Leana Wen, a Chinese-born American physician has to say about Health reform: China offers a cautionary tale.

 “The reforms of the 1980s changed healthcare from being a social good to a commodity. Universal insurance was dismantled, and 900 million people lost coverage overnight. Healthcare was decentralized to provincial governments, who allowed the market to operate with few restrictions.”
“What’s emerged is a fragmented system fraught with inefficiencies and perverse incentives.”
“… America … should learn from China’s experience and decide whether they see medical care as a commodity or social provision, and what are the responsibilities of the government to ensure the health and well-being of its citizens.”

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