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.