18 Nov 2010
15 minute read
agk’s Library of Low Resource Medicine
It is with trepidation that I bring up the barefoot doctors of China. Created as part of the Rural Cooperative Medical System in China during the Cultural Revolution, the barefoot doctors were rapidly trained farmers and factory workers who served in their home communities as a sort of volunteer fire department of primary care. Their training included an intensive background in public health and sanitation, a stripped-down western-style pharmaceutical toolkit, acupuncture and herbs. Since the 1971 explosion of information in the US about “traditional” Chinese medicine, the barefoot doctors have been heavily romanticized by Westerners looking for a more friendly vision of what health care could be. With their short training period, autonomous practice and promiscuous embrace of materiae medicae, the barefoot doctors appealed to the DIY counterculture in the US and Europe, indeed the blurb on the back of my translation of A Barefoot Doctor’s Manual is from the Whole Earth Catalogue review, and ends with the statement “if I were a nurse on a commune, this would be my main source book.” I find much fascinating in the barefoot doctors program, but for reasons that should soon be clear I do not endorse this idea.
After winning the Chinese civil war, the new communist government inherited a country containing ten to twenty thousand doctors of western medicine, approximately 500,000 doctors of Chinese medicine, and a population of well over 500 million. Chinese medicine at the time was secretive and unpublished, often hereditary, and diagnoses and treatments varied widely between practitioners. There were few medical records and no oversight. Western-trained practitioners were few and urban. Markers of public health were poor, and the eyes of the world were on China.
Mao commanded that post-revolutionary China would be “new,” “scientific,” and “unified.” This had to include healthcare. During the war, researchers with the General Health Department of the People’s Army had developed what would come to be called “the New Acupuncture” as a portable treatment modality appropriate for guerilla warfare. After the end of the war, one of these researchers, Western-trained Dr. Zhu Lian, published a textbook of her work in the army that did qualify as new and scientific. Academies throughout China began offering enrichment classes to doctors of Chinese medicine who wished to “scientize” and standardize their practice, although those who worked with the Ministry of Health were generally relegated to promoting hygiene, nutrition and immunizations. For a while, this compromise – hiring traditional practitioners, but only in peripherally medical capacities – seemed to work. To quote the book I’m using as a source, here:
Mao evidently saw the profession of Chinese medicine not so much as a therapeutic practice, but more as a large, and therefore significant, body of people. Mao’s support of Chinese medicine during this time can be linked to a concern for adequate health care manpower, and by extrapolation, to a concern for social stability. If the Chinese medical practitioners were ignored and not forcibly, as it were, integrated into the new Communist society, and if their medicine was not encouraged, it would mean hundreds of thousands of people without any means of support. It is likely that Mao interpreted the more serious problem to be one of economics, and the importance of keeping people usefully employed within society, rather than the dangers of supporting a potentially ineffective medicine.1
Eventually, however, the gap had to be closed. The early 1950s saw a series of disastrous attempts to regularize Chinese practitioners. Certification exams were instituted. Existing practitioners were eligible only for temporary certificates, and then only if they “enjoyed good repute among the people.” The new Beijing Chinese Medical Institute offered enrichment classes to Chinese practitioners in preventive medicine, New Acupuncture, and standardized Chinese prescriptions. Only 14,000 practitioners passed the new exams with scores of 50% in part one and 60% in part two (the minima for certification) and in some regions the fail rate was 90%. The new national health insurance did not cover Chinese medicine. The ministry of health came under attack for its policies, and in 1954 Mao dictated that “scientizing” Chinese medicine would not be sufficient to bring about his goal of a unified health care system. Instead, something rigorous would have to be re-created from the ground up.
In 1955 or 1956, China established the first academies of the newly renamed “Traditional Chinese Medicine.” This single, unified system, taught academically, was to replace the variable undocumented oral traditions of earlier Chinese practice. At the head of the Beijing Research Academy was none other than New Acupuncture founder Zhu Lian.
It is worth pointing out that the Korean war, which had just ended, had set communist China in full conflict with the capitalist west, and the first rumblings of the 1961 denunciation of the Soviet Union were straining the diplomacy between the world’s two communist superpowers. China, the oldest bureaucracy on earth, had spent a humiliating century as a virtual trade colony, first to the English and Portugese, then to Japan. “Patriotism” in the Middle Kingdom required embracing a Chinese identity, not only in politics and national identity, but in the sciences and medicine as well. Here, China is following in the footsteps of the Soviet Union, which rejected “bourgeois genetics” in favor of Lysenkoism; in many ways the Chinese were lucky, since unlike Comrade Trofim’s eternal punchline, Chinese medicine did actually have a multi-millenial history of empiric refinement. Traditional Chinese Medicine may not be traditional in its current form, but it is absolutely and irrevocably Chinese.
The Great Proletarian Cultural Revolution was a period during which the CPC attempted to purge the entire nation of China, but especially the echelons of power, of the influence of “liberal bourgeois elites.” Often, this meant re-education or, often for doctors, compulsory service “in the country.” It also meant a lot of executions and – oddly – the emergence of the barefoot doctors.
Beginning in the “Great Leap Forward,” productive life throughout China was reorganized into brigades and communes – entire communities focused on a single productive enterprise, be it a collective farm or a factory. Each brigade or factory lived, cooked, managed property, and received public services as a single unit, including food rations and, eventually, health care. The political ideology of the Cultural Revolution effectively prohibited educating a class of professional doctors, in the sense we think of them today. Doctors, after all, would be a privileged class of technocratic intellectuals, and would not be able to join with the peasants and workers. Furthermore, educating enough doctors to provide health care to all the newly reorganized collectives in China would have been a difficult task in the best of times, and these were not the best of times.
The functional, and politically acceptable solution was to inaugurate a new training program for the “peasants and workers” themselves. Brigades and communes would be able to designate members who showed an academic aptitude as well as an acceptable political outlook to undergo a training that lasted as little as six months. The only formal educational requirement was a high school diploma. On completing their training, they would return to their home commune and continue to work in their previous capacity as a farmer or a factory worker. For up to half their working day, however, they could function as an unpretentious, unbourgeois primary care physician, albeit at the same hourly rate as the other half of their day. They weren’t expected to go without shoes, but the term “barefoot doctor” came to represent this enforced humility.
In evaluating the barefoot doctor program, one must always be mindful of the political circumstances that led to its creation, and the restriction these pressures have placed on evaluation and historiography. Our colloquial understanding of the program here in the west is grounded largely in romanticism and propaganda. The RCMS ended in 1981, and a brief pilot program to revive it in the early 90’s focused more on the financial arrangements of insuring rural China than on the treatment modalities or the de-professionalization of the barefoot doctors. To a great degree, these two characteristics are up for significant debate.
For instance, despite a formal intent to create proletarian health care, possibly 20% of barefoot doctors went on to become professional doctors of western medicine. China’s current Minister of Health, a physician, began as a barefoot doctor. One imagines that many of the high school graduates who entered the program would have rather gone to medical school in the first place, but were unable to do so due to economic and political pressures of the time.
Secondly, the contemporary claims made for the efficacy of TCM in health care are somewhat dubious. James Reston’s famous article on how he had his appendix removed under acupuncture anesthesia started a revolution in the US – but in fact, his acupuncture was augmented with lidocaine and narcotic analgesics, something often not mentioned in secondary sources. Many articles have been written on a single photo taken of a woman undergoing heart surgery with only acupuncture anesthesia – and no ventilator. While alternative explanations have been proposed, the surgery as originally described would have compromised the intrapleural space and collapsed her lungs without positive-pressure ventilation.
I won’t pretend to answer whether TCM “works” or not (see my last entry on why) but it is worth noticing that the Chinese government was willing, in the 1970s, to fudge data to convince the world that it did.
Accordingly, the Barefoot Doctor’s Handbook should be read with a skeptical eye. There were, allegedly, multiple manuals appropriate for each province, focusing on more geographically appropriate treatments and conditions. The version translated into English, from Hunan, contains no information on mental health conditions, and no STDs. It is reasonable to assume that these existed, and it is reasonable to assume that barefoot doctors who had been issued penicillin (good then as now against syphilis) and chlorpromazine (listed in the manual as a “tranquilizer”) would probably have been familiar with these less decorous disorders. Furthermore, it is likely that separate regions, separate heirarchies, and even individual practitioners had their own prejudices about when to use the western, herbal, or acupuncture treatment modalities in the book. It is entirely possible that barefoot doctors used no herbs at all when western tour groups weren’t watching. We can’t know this, but we can’t assume otherwise either.
A listing of the medications mentioned in the manual is also instructive, as is a comparison to the WHO’s List of Essential Medicines. Many of the specific drugs have been replaced by safer or simpler drugs, but the overall balance between classes is largely the same.
What is interesting and undeniable about the barefoot doctors is that they were, ultimately, quickly and effectively trained, served without requiring enormous salaries, and were at least on some level closer in social status to their patients than doctors are in the US today. The same person who came to a barefoot doctor for antibiotics may have been wrestling bales of feed onto a truck with their doctor only hours earlier. The person in line at the kitchen telling jokes about the food might well be responsible for managing an epidemic of food-borne illness if the jokes turned out to be true. This is a level of social levelling I have experienced as a paramedic, and seen even with physicians in very small towns, but which is overall lacking in the US. In general, practitioners occupy a lofty social station from which they descend only to issue pronouncements about other people’s bad habits, and occasionally to run for public office. If one’s children go to the right sort of school, one might run into a doctor at a PTA ice cream social, but the economy depends on few of us going to that sort of school.
Even in med school, I have been told by instructors never to show doubt or uncertainty, and to take control of a patient interaction with authority. To some extent this is what patients expect – its what they’ve grown up with, after all – and to behave otherwise is to seem un-doctorly. However, it is also sometimes highly dishonest to act confident or authoritative, and even when physicians do have a degree of certainty – that smoking is bad e.g. – giving instructions from a position of authority seems much less pleasant to me than giving advice at eye level. Furthermore, many practitioners slide quickly into authoritarian interactions, or worse – insulated by money away from the social determinants of their patients’ diseases, they may come to think that their life represents a personal example that their slothful, slovenly patients should – must – follow. Everyone, not just nurses on communes or rural Chinese, can do a great deal better than that. This, ultimately for me, is the lesson of the barefoot doctors.
Taylor, K. Chinese Medicine in Communist China, 1945-63: A Medicine of Revolution. New York, Routledge. 2005.
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