Rural China misses 'barefoot doctors'
By Alexander Casella
Although China's "barefoot doctors" scheme relied on primitive supplies and
under-trained doctors, it was an iconic institution during the troubled times
of the Cultural Revolution which was later acknowledged by none less than the
World Health Organization (WHO) for the pioneering role it played in the
development of China's rural primary healthcare.
When the communists come to power in China in 1949, the country had some 40,000
doctors for a population of some 540 million, which meant on average one doctor
for some 13,500 inhabitants (the figure today is one for 950). The vast
shortages in terms of numbers was compounded by another problem. Most of the
doctors were in the cities and except for some practitioners of
traditional medicine, the countryside was practically deprived of any real
medical care and epidemics. This meant infectious diseases and poor sanitation
were pervasive.
While many of its top leaders were of urban or semi-urban origin, the communist
movement in China derived its strength from the fact that it had succeeded in
mobilizing the peasantry in its support and, once in power, the party made
rural healthcare one of its priorities.
With trained doctors in short supply, the central government in 1951 decided
that basic healthcare in the countryside should be provided by health workers
rather than by fully trained physicians. In 1957, there were more than 200,000
such "village doctors" whose administration was under the responsibility of the
local authorities. While these village doctors had received only basic training
and could not treat complicated cases, their impact was considerable and
especially so in preventing minor ills or wounds from developing into complex
medical problems and in implementing nation-wide vaccination campaigns.
In 1968, the village doctor program was renamed "barefoot doctors", with the
name derived from southern farmers who would often work barefoot in the rice
paddies. It was presented as one of the great achievements of the Cultural
Revolution. Actually, it had been in force since long before but the rebranding
suited the politics of the time. With millions of "educated youth" sent to the
countryside, the barefoot doctor scheme acquired an iconic dimension. Actually,
it was nothing more than ideology on the rampage combined with a reform of the
existing medical system, which now included an expansion of the short-term
training program of village doctors.
Reducing the number of years of training for doctors, a policy that now applied
to all university education - was very much an obsession with Mao Zedong. The
chairman had a strong mistrust of doctors, including his own, and used to claim
that six or more years of medical training were a waste of time and resources
when one or two were sufficient.
Given the state of China's economy at the time, this view was not totally
misplaced except it was not derived from an objective analysis, but rather from
a personal suspicion of the medical profession. If implemented, it would have
set medicine backwards in China for decades.
Nonetheless, the impetus it gave to overall rural healthcare was considerable.
Even though the supplies provided to the barefoot doctors - generally a few
medicines, some needles and syringes and not much else - was primitive. Therein
lay the weakness of the system; it provided the rural poor with a level of
healthcare unknown before the revolution, but was unable to develop beyond the
requirements of the most basic of health needs.
Given, however, the requirements of China at the time, the flaws in the system
were slight as opposed to the program's achievements, an accomplishment that
was acknowledged by the declaration of Alma Ata of September 12, 1978, when a
WHO-sponsored conference recognized China's achievements in public health as a
milestone for Third World countries.
Initially, the barefoot doctor scheme survived the Cultural Revolution and in
1980 the State Council directed that, after having passed an examination,
barefoot doctors could qualify as village doctors. This was hoped to fill the
gap in rural areas between primary needs provided by barefoot doctors and
advanced healthcare provided by fully trained practitioners.
The rural health system started to collapse in the late 1970s and early 1980s
as a result of China's economic liberalization and the privatization of
agriculture. Local medical facilities that had been financed collectively by
the communes lost their source of income and had to close down. This in turn
led to a collapse of primary healthcare and inoculation facilities and the
result was that many diseases that had been eradicated re-emerged in the
countryside.
Regarding hospitalization, the user-pays system introduced in the 1980s left
many rural patients, practically all of whom had no health insurance, unable to
pay for medical care, which led to a further decline in rural health standards.
While the authorities were not totally unaware of the collapse of the rural
health system as a price to pay for de-collectivization, no systematic measures
were taken to redress some of the downsides of economic reform. Indeed, in this
field, like many others, the regime demonstrated its inability at implementing
parallel policies rather than skipping from one priority to another. By the
early 1990s, the government had not only done away with the constraints of
collectivization, but had also, in the process, seen the collapse of the rural
healthcare system. This was akin to throwing the baby out with the bath water.
The end result, according to the WHO, is that China is medically speaking two
nations.
Primary care, even in the cities, is almost non-existent and with no
independent doctors or neighborhood clinics, people have to go to hospitals
even for simple healthcare needs. With hospitals told to finance their own
costs and 79% of the population having no health insurance, the burden on the
average Chinese is considerable, with the result that many simply cannot afford
any healthcare at all.
The one to 950 ratio of doctors to the population appears encouraging, but it
only reflects part of the picture. It compares favorably to one for 500
inhabitants in Japan, 400 in Australia and 300 in Western Europe as opposed to
1,700 in India and 50.000 in Tanzania. But these numbers don't reflect the fact
that most of China's doctors are concentrated in the cities. Likewise, while
most general hospitals are clearly below Western standards aside from a few
specialized hospitals which routinely perform complex operations with
well-trained doctors and the latest equipment. These are increasingly catering
to the need of the newly affluent Chinese.
In a country where large swaths of the population do not have access to the
most basic healthcare, it is this group which spends an estimated $2 billion a
year on cosmetic surgery. This can only increase the gap between the haves and
the have-nots.
According to current estimates, it would take half a million additional
doctors, well distributed across the country, to provide the healthcare that
the Chinese really need. This, however, would require not only additional
training of doctors but also a reform of their status and remuneration. This
would go a long way towards reducing the exodus of Chinese doctors, an
increasing number of whom are now practicing in Africa, where they not only
receive better wages but also have a higher social standing.
According to Western medical sources, the Chinese government is coming to
realize that it needs to address what could develop into a major health crisis
in rural areas, but there remains a large question mark over what priority they
have set for this and how they plan to address it.
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