Li Yanhong

BAREFOOT DOCTORS

22 January 2008

[The “barefoot doctors” were one of the Cultural Revolution’s “new-born things.” The term refers to young peasants or rusticated urban youth who were given rudimentary medical/first-aid training and were expected, while continuing to work the land, to serve as well as providers of health-care in the villages. This program was probably the best-conceived of the Cultural Revolution innovations, inasmuch as Chinese villages lacked (and still lack) easy access to doctors, hospitals, and clinics. This nostalgic look backward to the good old days of the Cultural Revolution is unusual in itself, and while possibly romanticizing the barefoot doctors, ignores the nastier aspects of the campaign, particularly the attacks on trained medical specialists. This essay notes the program came to an end in 1985: the barefoot doctors were expected to derive their livelihood from work points earned in agriculture, as part of the collective economy. By 1985 the collective economy had collapsed, and there was no way to remunerate the young paramedics. The barefoot doctor system was replaced by a system using supposedly more highly trained professionals, who were paid for providing the medical services that the barefoot doctors provided as a sideline. It would be interesting to know whether the general quality of rural health care has deteriorated since the Cultural Revolution era.]

The term “barefoot doctors” is one that is familiar to people today, but also very distant. For almost 20 years, from the first appearance of the concept in reports in 1968 until the decision by the Health Ministry to end the use of that term, on how many hundreds of thousands of villages were there clinics staffed by these state-designated unofficial physicians who served the basic health needs of the 600 million peasants?

This broadly based supplementary health care requiring only a minimum of investment received widespread international praise. It was a glorious page in world medical history.

June 16 Gave Birth to the Barefoot Doctors

At the celebration of the 20^th anniversary of the Republic’s founding on 1 October 1969 a great ceremony was held at Tiananmen Square. The footage of the film of the ceremony by the Central News Bureau includes this scene: Mao Zedong is standing atop the Gate of Heavenly Peace, wearing a light blue Sun Yat-sen jacket. The wind blows through his hair and the sunlight of early fall make him squint his eyes. One by one trained groups pass in review before the gate, shouting slogans and being reviewed by Mao Zedong. Then a special group comes into his vision, and the 76-year old Mao Zedong bends down and gives that group a special wave. In that group there were about 1000 young rural girls carrying medicine satchels and wearing peasants’ straw sun hats marching barefoot. Their banner read: “In the Work of Health and Healing, Put the Emphasis on the Countryside.” This was borne by a special vehicle.

That group represented a total of several million barefoot doctors at that time.

On 1 October 1969, standing atop the Gate of Heavenly Peace, Mao Zedong was pleased. He saw that the movement for barefoot doctors that he had advocated four years earlier had already become a strong force.

In the period following the founding of New China the country was beginning to recover from major destruction. The limited medical facilities were then largely concentrated in the cities. The lack of medicine and medical care in rural areas became a perennial concern for the Party and state. In January 1965 Mao Zedong and the Center approved a report from the Ministry of Health concerning the organizing of mobile medical units at the rural base. The proposal was that in the first half of 1969 the “cities of the country organize 2800 people to go from place to place in the countryside providing medical care.” The program was under the direction of Li Changming, who had previously headed the basic level medical care and gynecological sections of the Ministry of Health.

According to Professor Yang Nianqun of China People’s University, who has made an in-depth study of the history of the barefoot doctor movement: “The circuits covered by the medical teams were too narrow to cover the demands and aspirations of the peasants. It was all distant water to quench a present thirst. The amount of time that could be devoted to cures was a superficial aspects of this. The real problem was that there were no long-term doctors resident in the countryside.” “Mao Zedong was the son of peasants. He knew that this kind of nomadic medical care would provide only temporary remedies. How could the peasantry attain solid medical care? That was one of his heartaches.”

On 26 June 1965 Minister of Health Qian Xinzhong reported on this work to Mao Zedong. At that time there were about 1.4 million trained medical personnel in China. Among the highly trained physicians, 80 percent were concentrated in urban areas. Of these, 70 percent were in large cities and 20 percent in county seats, leaving only 10 percent in the villages. Only 25 percent of the medical budget was spent in the countryside, with 75 percent allotted to the cities. Mao Zedong became angry when he heard those statistics.

Li Changming once asked Qian Xinzhong about this meeting. According to the story, Mao Zedong stood up and said in a serious manner: “The Ministry of Health is working for only 15 percent of the population and most of that 15 percent are aristocrats. For the broad peasant masses there are neither doctors nor medicine. It ought to be called the Urban Aristocrats’ Ministry of Health.” “Let’s cultivate a large cadre of medical workers from the countryside itself and let them serve the health needs of the peasants.”

Following this, in a brief time relatively well-educated barefoot doctors proliferated in the countryside like spring grasses after a rain. By means of “one acupuncture needle and one bag of herbal medicine” they served the rural population. This was a lively and picturesque symbol of the times.

The Barefoot Doctors Made Their First Appearance in 1968

In 1965 the Jiangzhen commune in Chuansha county, Shanghai, instituted a speeded-up training program. Wang Kueizhen was one of a group of 28 health workers in Jiangzhen. After a short four months of training, Wang Kueizhen took up a medicine bag and went door to door in the village visiting patients. Huang Yuxiang was a retired teacher in Shanghai’s New Pudong district School of Hygiene. After graduating in 1953 from the Jiangsu Medical Academy he had been assigned to the clinic in Jiangzhen. After practicing rural medicine for two years, in 1965 he was put in charge of the training program. He was Wang Kueizhen’s first teacher of medicine.

The universalization of rural medical care developed rapidly throughout the country, in accord with the directive of Mao Zedong. A people’s hospital was set up in each county of the country, with a clinic in all units at the commune level and above. In each village there was a health station. This constituted a three-tier system of rural medical care. At the same time the Ministry of Health moved to train rural educated youths in medicine. There rapidly arose a corps of half-time farmers, half-time doctors.

In the summer of 1968, Shanghai’s Wen Hui Bao published an essay entitled “The Direction of the Revolution in Medical Education as Shown in the Cultivation of ‘Barefoot Doctors.’” This was in fact the report of an inspection of the barefoot doctors trained in Jiangzhen commune. It introduced the world to the whole-hearted service to the peasants by Huang Yuxiang and Wang Kueizhen. That same year the third issue of Red Flag and the 14 September edition of the People’s Daily republished the essay in full. This was the first time that the halftime farmer, halftime doctor rural medical workers were termed “barefoot doctors.” That same day Mao Zedong added his notation to the People’s Daily: “Barefoot doctors are a good thing.” Thereafter barefoot doctor became the regular term for this kind of medical worker. Wang Kueizhen was regarded as first among the barefoot doctors. Shanghai’s food coupons in 1977 carried her image.

Huang Yuxiang said: This is something demanded by the peasants themselves. The villages in the south are all flooded rice paddy, so you have to go barefoot when you wade into the water. Barefooted, therefore, implies participation in labor. Barefoot doctors engage both in farm work and in medicine.

The barefoot doctors were intimately bound up with the program for rural cooperative medical care that was being implemented on a country-wide basis at that time. The barefoot doctors were a loyal implementation of that program. The model for cooperative medical care had been set up in a Tujia community, Shanzhai, in western Guangdong, by one Tan Xiangguan. On 10 August 1966 China’s first experimental cooperative clinic, the “Happiness Garden Commune Tujia Village Brigade Medical Station,” first hung out its sign. Tan Xiangguan took the initiative of giving up the “iron rice bowl” of the commune clinic and became a “barefoot doctor” in the Brigade health station, living on work points and eating the grain grown in the village. Each peasant each year paid a medical fee of one dollar, the Brigade retaining half of this in its collective fund as capital for the clinic. Aside from a few people with chronic illness who needed medicine all the time, the masses would pay a five-cent registration fee each time they came for treatment. Tan Xiangguan’s Rural Cooperative Medical system, in which medical treatment was given free, came to be promoted in 90 percent of the villages in the whole country, thanks to Mao Zedong’s personal approval of it and a front-page report on it in the People’s Daily. The system brought benefits to millions of peasants.

No one has a clear idea of the evolution of China’s rural medical system. However, in a large agricultural country the lack of medical care and medicine in rural villages was a perennial major concern to the state. The historical materials go back at least as far as the Tang dynasty. At that time there was a state system for sending doctors to the countryside. Emperor Xuanzong of the Tang supported a medical school in each district, playing a major role in organizing a mobile medical rank and file for rural areas. In the Song dynasty there was a “Medical Bureau for Nurturing the People,” in which sick persons could be examined and receive treatment for free. It was relatively convenient for ordinary people to receive medical treatment.

The greatest influence on a world-wide scope was probably Chen Zhixian’s Dingxian Model.” Chen Zhixian, our country’s pioneer in public health work, received a medical degree from Harvard, in the United States, in 1932. He traveled to Dingxian in Hebei by mule cart: thus began the world-famous “Dingxian model.” The first thing Chen Zhixian did was to train rural health care workers, who undertook propaganda about disease prevention, smallpox vaccination, and well-water purification. They could use the medicines in their kit to treat trachoma and ringworm and give emergency treatment for wounds. They improved their own water wells and latrines and showed their neighbors how to do this as well. They also kept a register of births and deaths in the village and were able to refer those in need of more complicated treatment to the proper doctors and clinics. They set a three-tiered network for medical care from the township to the village to the county. But, alas, this practice, which had attracted the attention of the world, was forced to shut down after the Marco Polo Bridge incident in 1937.

In his memoirs the first American doctor to claim Chinese citizenship, George Hatem, says that the barefoot doctors were an extension of the method used in the Red Army. That year the medical training facilities in the soviet areas had to churn out a corps of medical workers in 18 months. As he remembers: “In the Liberated areas and the Red Army, the number of doctors who had been trained in regular medical school could be counted the fingers of two hands. So almost all the burden medical work was borne by those who had undergone that short-term training. Thus, the training of half-time doctors is an old tradition. The concept of “barefoot doctors” existed even back then, except they did not have that name.”

Training the Sons and Daughters of the Poor and Lower-Middle Peasants to Become Doctors

What kinds of people were able to become barefoot doctors? In that era of politics first, it must be those with red roots, the sons and daughters of the poor and lower-middle peasants. They also had to be able to read and have at least a primary school education. Their relatively low cultural level, the narrowness of vision as a consequence of rural life, and the gap between simple labor and brain labor meant that in the class room these study personnel would nod off and sleep. What could be done to wake them up and to give them the necessary medical knowledge in a short period of time. This was something that the teachers had to think about and apply their skills to.

In October 1965, as the fall colors were on display, Liu Zhongyi accompanied the medical team sent down to villages in Hunan. His job was to train the rural health workers. Liu Zhongyi had a complete understanding of the study characteristics of these young peasants. They were enthusiastic but lacking in patience. In less than ten minutes after the beginning of a classroom lecture some would begin to nod off, their heads bobbing like chickens pecking at grain. They had no use for the materials in the training center. While teaching a class on infectious diseases, Liu Zhongyi had the students put their texts back into their book bags and instead organized the class as a discussion of a murder mystery. According to the story, a janitor discovered the body of a train passenger while cleaning a shed outside a small station in Hunan. There were bloodstains all over the shed. The public security personnel began their investigation with an analysis of the bloodstains. The atmosphere in the classroom changed immediately. The “classroom detectives,” under the guidance of Liu Zhongyi, came easily and naturally to an understanding of blood types. It was discovered that within the blood there were malarial parasites and schistosome flukes. Putting this together with a study of the lives and habits of such creatures, they were able to conclude that the deceased had come from an epidemic-stricken area and also that the murder had occurred around midnight, since the larvae of schistosome flukes are found in the bloodstream only around midnight, according to the life-habits of those creatures. The process of cracking the case brought together information on blood-typing and the relationship between parasites and illness. Where did the temptation to nod off go?

In conducting the training it was necessary to take into consideration liveliness, popularization, practicality, and precision. In the cultivation of knowledge the teacher had to avoid language like “carbohydrates are a source of energy,” that kind of terminology. Rather, he should say: “Brown rice is more filling than white rice; boiled rice is more filling than steamed rice; if you eat steamed rice, you should also drink the water in which it has been cooked.” In training for first aid it was more important to teach how to treat bleeding head wounds than to teach artificial respiration, since the first is very common in rural areas.

The main areas of the curriculum included: treatment of superficial wounds; treatment of common minor illnesses; basic methods for prevention of disease; treatment and prevention of common chronic diseases; the properties of simple medicines.

The Publication of Barefoot Doctor’s Handbook in Numbers Second Only to the Selected Works of Mao

“Prevention of Bites from Rabid Dogs.” Ordinarily a rabid dog will hold his neck stiff. His head will be lowered, his ears will droop, his tail will drag on the ground. He will walk straight ahead, unable to turn around and look back. When you see a rabid dog you must find some way to kill him and then burn the carcass. If you are bitten by a dog and there is no way to tell whether the dog was rabid or not, give immediate attention to the wound and also get the necessary vaccination.

. . . . .

Lice are parasitical insects once common in rural villages. They not only bite and suck blood, but in sucking blood they can transmit relapsing fever, spotted fever, and other infectious diseases. The main way to prevent lice infestation is to pay attention to hygiene; change clothes frequently and take frequent baths. (From “Exterminate Lice”)

(1) Washing the hair with vinegar will help loosen the nits. Use a bamboo comb to remove the rest of the nits. Rinse in baibu [stemona: a flowering plant, one of the50 fundamental plants in the Chinese phamacopia] water (boil one ounce of baibu for 30 minutes in two jin of water, then strain), rubbing it into the head. Wrap the head in a towel, and in the morning the lice will be dead.

. . . . .[AC1]

There are many ailments that can cause coughing. What should be done if the throat is inflamed? Thoroughly wash two jin of turnips; without peeling the skin slice thinly; squeeze out the juice and administer orally.

Apply the juice of pulped fresh ginger to the tip of the tongue, or administer the juice orally.

Boil and drink a soup made from soy sauce. These are methods for treating nausea.

These are prescriptions found in the Barefoot Doctors Handbook, published in 1969. It gives herbal prescriptions for cure and prevention of illness and simple procedures to be used when there is no opportunity to get a specialized doctor.

This handbook provided guidance for a whole range of ailments, from the common cough to nausea to complicated ailments such as heart disease, blood disorders, or cancer; from the elimination of mosquitoes and flies to measures to guard against damage from nuclear and chemical weapons; from acupuncture and herbal medicine to the more commonly-used western medicines: everything was covered.

Jin Dao, a 68-year old retired professor, told reporters: “The Barefoot Doctors Handbook was not only reading material for rural doctors. It seems that at that time all urban families also had that kind of book. It was very convenient. My children were young then and would always have all kinds of minor ailments. I got into the habit of leafing through that book to be able to identify symptoms and treatments. What do you do for chicken pox? How do you treat cold sores? The Handbook has an answer to everything. Look—I’ve thumbed through that book until it’s all worn out.” The thick book in Jin Dao’s hands was all frayed and torn pages had been glued back together.

In 1969 Huang Yuxiang’s clinic at Jiangdian Commune was given a special task of drawing up teaching materials for barefoot doctors suitable for the southern regions. In addition to serving as in-service training texts for barefoot doctors, the majority of these were books popularizing medical knowledge geared toward raising their medical skills. The proposals by Huang Yuxiang became in the nature of things the source material for these works. In June 1970 the People’s Health Publishing Company published Training Text for Barefoot Doctors (Specially for the Southern Regions). At first 500,000 copies were printed; but because of the demand there were repeated printings, ultimately to the total of 1.18 million books.

The teaching materials gave the barefoot doctors an introduction to the most rudimentary beginners’ methods. Subsequently revised editions of the training materials were published for both the north and the south. In 1969 the Shanghai Chinese Medicine Academy and the Zhejiang Chinese Medicine Academy jointly published the Barefoot Doctors Handbook. That book, with its dark purple patent-leather cover, immediately became a national best-seller. It was in the hands of barefoot doctors everywhere, whatever their locality. It did not follow the traditional path, moving from anatomy to chemistry to pharmacology, but centered on particular questions. It was clearly written and easy to understand, geared toward practice. It became the model of a successful text.

Over these thirty long years the Barefoot Doctors Handbook not only did yeoman’s work in helping millions of people with their health problems in the age of scarcity, but has continued to be a guidebook to health for the Chinese people. Its circulation is second only to that of Selected Works of Mao Zedong.

The Handbook has also been the object of international attention. There are translations in America, England, and by UNESCO. It has been translated into more than 50 languages and has circulated throughout the world. The English translation can be found to this very day in certain western bookstores.

Nurturing, Applying, Keeping

The 16-year old Jiang Guiling graduated from junior high school on 3 April 1975. After being selected by all the commune members in her village, she joined the barefoot doctors training class of Zhougoudian commune in Fangshan County. After three months, she returned with her medical bag to Lianggezhuang, becoming the only barefoot doctor in the village.

Could a child of 16 really diagnose illness? You need to have courage and gird yourself for battle, Jiang Guiling said. Because she was courageous, her first patient enabled her to establish her reputation in the village. “That was an old lady who liked to drink and also had high blood pressure. One noontime after drinking she went to the bathroom and fell down. The latrines in Fangshan village are all made of stone and when she fell she injured her face on the stones. There was a cut four centimeters long that would not stop bleeding. Her family called for me and when I saw her I was scared to death. I said I didn’t dare do anything, and that medicine alone would do no good. I urged her to go to the commune clinic. The old lady said she’d bleed to death before she got to the clinic. I thumbed through the book trying to find what to do in such cases. I got out my suturing kit and, working up the nerve, sewed her up, just like sewing clothes. I didn’t worry about the size of the stitches. I was sweating all over, but when I finished she was no longer bleeding.”

After she had stopped bleeding, whenever she would run into people would always say, That little girl Guiling is as good as a real doctor. She only studied for a few days, but she knows how to heal wounds.

The barefoot doctors were peasants first of all. They’d put down their medical bag to work the land and pick it up when they had to treat someone. They depended on work points from the production team to live, and so they were affordable. They lived among the peasants and so were always available, no matter what the time or the weather. They also had good personal relations with their neighbors and so were able to be effective. Their household registration was in the village, as were their families and their social relations. They were not like the circuit doctors who would come and go but were always in the same place with their medical skills.

“Yu Jinming was 50 years old that year. He was working on the mountain, piling up stones. He suddenly keeled over, the victim of a heart attack. When I was called up to the mountain they said he had been unconscious for 20 minutes. I felt for his pulse in his wrist and neck and stuck in acupuncture needles at the appropriate places. After a while, Yu Jinming came to. If there had not been timely action, I’m afraid he would have been gone. The nearest hospital to our village was 26 kilometers away, over a mountain road. There was no way to send him to the hospital.” This is the story told to reporters by Yu Yuantang, who since 1965 had been a barefoot doctor in Nantianmen village, Zhenzhuchuan township, Yenqing county. The story drives home a fact: The most useful doctors are those who are closest to the peasants.

Zhou Ping worked with Hu Yuying as a barefoot doctor in Limin Street in the town of Yongning in Yanqing county. They served more than 1700 people in the town itself, along with numberless others from the nearby towns. There might be some in that town who didn’t know who the mayor was, but there was no one who did not know Zhou Ping. In 2005 Zhou Ping, who had been treating people for more than 39 years, contracted uraemia. She could not afford the expense of treatment. But when the townspeople learned of her plight, within a week they had collected more than $6000. Zhou Ping said: I can’ accept this. I won’t be able to practice anymore, so I have no way to pay it back. That will make me feel bad.” But Hu Yuying, who had assisted at the births of more than 300 children in the village, approached the issue from a different direction. He answered gently, “When these children grow up and get married, they certainly invite me to their wedding feasts; and when I see them on the street, I will continue to pat them on the cheek.”

Han Shaocheng, Hu Ping’s neighbor, said: “We’re all villagers; we don’t have any airs among us. Everyone is very familiar with everyone else. They help us out, and when they have problems we too lend a helping hand.”

“In Chinese villages there is a tradition of the doctor-patient relationship. When one is treated by a doctor the doctor becomes in effect one of the family. That is, the whole process of healing involves something like feelings of kinship; a nexus of human relations is created. The doctor uses ordinary words to explain the patient’s illness. Care for the patient is no less important than the treatment of the disease. It may even be more important.” That’s how Yang Nianqun explained the face-to-face doctor-patient relationship.

The villagers had complete respect for the barefoot doctors. The doctors enjoyed a high status, even more than that of the village cadres. In those days if one invited guests and a barefoot doctor were among the guests, both the host and the other guests would feel this was a very great honor. This kind of respect was not bred from fear but from a close feeling of dependence and trust.

Yu Yuantang lost both his father and mother when he was very small. He was raised by relatives in the village. He deeply felt a need to respond to this warm and gentle environment. “Without my relatives there would be no me. They raised me, and since I studied medicine I must selflessly treat their illnesses.”

“Their footprints were in a thousand homes, ten thousand families; the medicine chest accompanied by the scent of mud.” The barefoot doctors, who wielded the hoe and the scythe on one hand and on the other hand treated the sick provided basic medical care for China’s villages.

Two Talismans of the Barefoot Doctors: The Acupuncture Needle and Herbal Medicines

“Healing depends on the silver needle, and seek the medicine in the mountains.” Yu Yuantang says this verse accurately reflects the live of the barefoot doctors. “At that time, the needle and herbal medicine were our two treasures. At Springwater village, 27 li [nine miles] from our town there was a man named Shi Fuqiang. His face became paralyzed. He had a relative in our town and he came to stay with that relative. Using acupuncture together with herbal medicine, I was able to cure him in seven days.”

“Pick up the needle, read the book, try it out on your own self; that way you can more or less figure out where the key nodes are and also know what if feels like.” Jiang Kuiling began to experiment on herself with the needle when she entered training at 16 years of age. The most thrifty and effective use of acupuncture technique became the students’ most-sought goal. It seems that every single barefoot doctor knew that technique and every single one of them had experimented on his own body.

In addition to this, another task of the barefoot doctors was to seek out and prepare herbs used for medicine.

Why? Because there was a real lack of medicine available to the barefoot doctors. Another name for the barefoot doctors in those days was “mercurochrome, iodine, and aspirin”: these, aside from a few pain medicines and antibiotic sera, were the entire contents of the barefoot doctors’ medical kits.

These circumstances meant it was necessary for the barefoot doctors to seek medicine in nature.

[Other duties of the barefoot doctors included hygiene and disease prevention work in the villages, including the administration of vaccinations.]

Summing up the reasons that the barefoot doctors were so well accepted by the peasants, Wang Nianqun says: First, they stressed Chinese and herbal medicine, and these suited the actual situation in the villages. Western medicine was the urban model. It was static and far from the needs of the villages. It was increasingly specialized and systematized. There was also a basic issue: it was a matter of capital—western medicine required a large capital investment. This was even the case with Chen Zhixian’s Dingxian Model: he adopted western medicine and rejected Chinese medicine, and as a result his methods could not be applied broadly. But a needle, a box of herbs, even local cures and techniques, none of these require much capital. And most of all, the relationship between the barefoot doctors and their patients was one that of relatives and fellow villagers, and this served to keep up good human relationships.

International Attention to the Barefoot Doctors

The 1970s were the golden age of the barefoot doctors. There were barefoot doctors even among the herdsmen in Tibet. All villagers felt ever closer to and warmer toward the barefoot doctors. To become a barefoot doctor was the life’s ideal of the rural youth at that time.

In 1972 there was a 52-minute film, “Barefoot Doctors in the Chinese Villages.” This aroused general international acclaim. The film was made by several scholars from Stanford University in the United States. It brought China’s barefoot doctors to the attention of the world and became the occasion for a general global fad for China’s barefoot doctors.

At the 1974 session of the World Health Organization in Geneva Wang Kuizhen served as the representative of the barefoot doctors. She made a 15-minute speech and was able to feel for herself the general esteem for China’s barefoot doctors.

In early September 1976 various international health organizations held a meeting in Manila, attended by representatives from 33 states or regions. Wang Yuxiang and Tan Xiangguan attended together, and each spoke separately on how to train barefoot doctors and organize collective medical care. Other speakers could talk for only 10 minutes. If they went beyond ten minutes they would be gaveled into silence by the chairman. But Tan Xiangguan, as head of the Chinese delegation, was able to speak and respond to questions for more than two hours. Tan Xiangguan’s report and his answers to questions aroused deep sighs of admiration from all those yellow-haired blue-eyed foreigners. They pointed toward Tan Xiangguan and said: “The population of rural China is so large. It’s a real miracle that you are able to provide cures and medicine without spending money.”

In the late 1970s high officials from the WHO made an inspection tour of China’s villages, proclaiming China’s collective provision of medical care as the “only model for resolving the problem of medical expenses in developing countries.” The UNICEF yearbook for 1980-1981 said that China’s barefoot doctor system was able to provide basic medical care in backward rural regions. It is a model of how undeveloped areas can improve the level of medical treatment.

The Twilight of the Barefoot Doctors

On a spring morning in 1982 a woman commune member, Huang Huaqiao, in Lingli Commune, near Nanning in Guangxi, was working in the fields. Suddenly she felt a sharp pain in her belly. She fainted and fell to the ground. The commune members who were nearby feared she had a severe acute illness and rushed over. Their first response was quickly to call the barefoot doctor. But someone said: The barefoot doctors have been disbanded and sent home; we need immediately to call the hospital. The ambulance quickly carried her to Nanning First Hospital. For 60 cents the patient was given an infusion of fructose and vitamin B. She recovered, but the ambulance had to make a trip of 40 kilometers, costing more than 10 dollars, not counting the loss of labor. After this some commune members complained that had the Great Brigade clinic not been closed down and there were still barefoot doctors, there would have been no need to travel so far or to spend so much money.

Beginning in the early 1980s, the barefoot doctors very gradually began to fade from people’s attention.

With the institution of the household responsibility system and the redistribution of rural land the barefoot doctoring was becoming a sundown industry. Land belonging to the collective was distributed to individual households. In the commune era, the head of the production team assigned the work of all the peasants in the village. This allocation of labor was a very sensitive issue, one which could easily give rise to contradictions. With the distribution of land to the household, the master had to set out the plan for planting, choose the crop, arrange for labor, and buy the materials for production. In the process of production the agricultural management unit became smaller and smaller, until at last it was on the scale of the family.

“The collapse of the work point system was a heavy blow to the institution of barefoot doctors. The barefoot doctors’ motivation for serving the peasants naturally arose from simple feelings of neighborliness, but even more their spirit and sense of achievement came from a feeling that their work was different from that of ordinary labor. They were following a higher calling. This sense of self-worth has been part of conscience formation from ancient times on. Therefore in the countryside barefoot doctors could earn work points and that was no small point of pride. But with the collapse of the communes there was nothing to sustain this system. Rather, they came to crave the money they could earn by work in the fields. This became a temptation hard to resist.” Thus the opinion of Yang Nianqun.

“The reason is very simple. The land is your own and your livelihood comes from work on that land. Without work points the barefoot doctors had to put a priority on earning their livelihood. They had to put down the medicine box and pick up the hoe.” That is what Li Changming said.

With the sudden decline in the remuneration of barefoot doctors there was also a decline in the morale of those who formerly enjoyed even more prestige than the Brigade cadres. This did not mean that the opinion of the barefoot doctors held by the peasantry became less; but it was hard to maintain the status of the barefoot doctors given the inequalities in remuneration.

Li Changming says, “When the barefoot doctor rank and file were disbanded, part of them returned to their old work as peasants, tilling the fields. The greater part were educated youths, and they returned to the cities. An important reason for the barefoot doctors’ movement reaching its peak in the 1970s was the rustication of educated youths. Lots of these knowledgeable and aware young people became barefoot doctors. But by the end of the 1970s there began a return to the cities. College entrance examinations were restored in 1977 and these were in the first cohort of those taking the test. The dispersal of the educated youths among the barefoot doctors exacerbated the dissolution of the entire system.”

Toward the beginning of 1985 the Ministry of Health issued a decision that the term barefoot doctor would no longer be used. The original barefoot doctors would be administered a test, and those who were qualified would be reclassified as rural doctors. Those who could meet this standard could continue to practice medicine. On 25 January the People’s Daily published an article, “Stop Using the Term ‘Barefoot Doctor’; Consolidate and Develop the Ranks of Rural Doctors.” With this, the history of the barefoot doctors came to an end.

However, the effectiveness of “Chinese model” continued to be recognized by the WHO and the World Bank. It “achieved the highest levels of health care with the smallest amount of investment.” From 1965 to 1980, more than 90 percent of the production brigades set up collective clinics, achieving a tri-level network (county, township, village) for prevention, treatment, and maintenance. In this network there were 510,000 regular physicians, 1.46 million barefoot doctors, 2.36 million brigade orderlies, and 630,000 visiting nurses.

Today many former barefoot doctors continue their training, serving as a major force within the framework of the new rural collective healthcare system.

“Barefoot doctor” has become a historical term. But the brown-fiber medical kit sitting in the fields, the visits from the doctor to your kang [heated bed made of brick]—these are the warm memories of that era.

Beijing Ribao, 22 January 2008