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 China’s barefoot doctors: What happened?

China’s barefoot doctors: What happened?
Posted by kasama on August 5, 2011




A photograph from the official promotion of the barefoot doctor program in the early 1970s.


by Jeffrey Hays

Barefoot Doctors
Doctors in the Mao era

In the Mao era, around 1 million “barefoot doctors” were give six months of training and sent out to countryside to open rural clinics, provide immunizations and offer basic medical care. They often wore straw hats and carried small wooden medical boxes from their shoulder.

Some of barefoot doctors only had an elementary school education. One 68-year-old man said he took an aptitude test on the suggestion of his mother. “They asked me, why does a train run so fast. I’d never seen a train before, so I racked my brain.”

The barefoot doctors traditionally roamed the countryside, visiting around a dozen farmers a day, charging them a nominal registration fee and giving out medication for free. They didn’t do anything too complicated. One doctor told the Los Angeles Times, “I don’t treat serious illnesses. I don’t know how.”

The barefoot doctor tradition lives on in services such as the Lifeline Express, a train that operates in poor areas in Xinjiang Province and offers cataract surgery for free to all comers. The cataract operations take 15 to 20 minutes, involve cutting the cornea and replacing a clouded lens with a clear artificial one,. The operations given in an assembly line fashion to patients by doctors who put in 12 hour days and volunteer their services for little pay for one-year stints.

Although China’s ‘barefoot doctors’ scheme relied on primitive supplies and under-trained doctors, it has been acknowledged by the World Health Organization (WHO) for the pioneering role it played in the development of China’s rural primary healthcare.

Treatment by Barefoot Doctors
Describing the difficulty in bringing good medical care to rural areas in China, one barefoot doctor told the New York Times, “When we go out and try to inoculate babies, some peasants are very frightened and hide their kids. Or they turn their dogs on us to bite us and drive us away…We give them injections for measles, and then the kid gets a cold. So the parents come, and complain. They say, ‘You promised that my child wouldn’t get sick!’” The inoculations themselves are fairly easy to give to young children because many of them don’t wear pants or they wear pants purposely made with holes in them..

These days the doctors don’t roam so much any more. Each village has its own doctor. A typical rural clinic run by a barefoot doctor consists of a single room in mud-brick, thatch-roofed building or concrete, tin-roof structure with a couple of bamboo cots, a desk and wooden cupboard with some pain, fever, diarrhea, and cold medicines inside. It typically doesn’t have a phone but it does have disposable needles, an improvement from the old days when needles were reused after they were swabbed with alcohol.

Rural clinics typically have dirt floors and lack sterilizing equipment, Many of the medicines are fake but are sold by doctors anyway because the drugs are their primary source of income. Equipment consists of a thermometer and a blood pressure machine that doesn’t work. Wish lists by barefoot doctors include a stomach pump, tools for extracting abscessed teeth, and oxygen cannisters for respiratory problems.

With the introduction of economic reforms and capitalism, money for public health has declined. Barefoot doctors see fewer people because their patients have to pay considerably more than they did in the old days and people get sicker less. One barefoot doctor told AP, “Now the job is easier because vaccinations have eliminated so many diseases, like measles.”

One their most successful herbal medicines, pumpkin seeds, was used to rid victims of worms. Today the treatment is also used in Africa to combat schistosomiasis.

Pre- History of Barefoot Doctors
Alexander Casella wrote in the Asia Times,

“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.”[Source: Alexander Casella, Asia Times, January 16, 2009]

“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.” [Ibid]

“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.” [Ibid]

Early History of Barefoot Doctors
“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.[Source: Alexander Casella, Asia Times, January 16, 2009]

“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.” [Ibid]

“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.” [Ibid]

“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.”

Collapse of the Barefoot Doctor System
“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.” [Source: Alexander Casella, Asia Times, January 16, 2009]

“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.” [Ibid]

“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.” [Ibid]

Rural China Misses Barefoot Doctors
Today 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 percent 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.” [Source: Alexander Casella, Asia Times, January 16, 2009]

“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.” [Ibid]

“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. “ [Ibid]

“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.”

Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, National Geographic, The New Yorker, Time, Newsweek, Reuters, AP, Lonely Planet Guides, Compton’s Encyclopedia and various books and other publications.
  
  
  

 
 
顶端 Posted: 2011-08-20 15:39 | [楼 主]
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China’s village doctors take great strides

Village doctors have dramatically improved access to health care in China’s rural communities over the last few decades. Cui Weiyuan reports.

China’s barefoot doctors were a major inspiration to the primary health care movement leading up to the conference in Alma-Ata, in the former Soviet Republic of Kazakhstan in 1978. These health workers lived in the community they served, focused on prevention rather than cures while combining western and traditional medicines to educate people and provide basic treatment.

Dr Philip Lee, then a professor of social medicine at the University of California in San Francisco, wrote glowingly in the Western Journal of Medicine about China’s primary health care system after visiting the country in 1973 as part of a United States of America (USA) medical delegation. He said prior to the founding of the People’s Republic of China in 1949, epidemics, infectious disease and poor sanitation were widespread. “The picture today is dramatically different … there has been a pronounced decline in the death rate, particularly infant mortality. Major epidemic diseases have been controlled … nutritional status has been improved [and] massive campaigns of health education and environmental sanitation have been carried out. Large numbers of health workers have been trained, and a system has been developed that provides some health service for the great majority of the people.”

Three barefoot doctors, part of a production brigade near Shanghai.
Dr Zhang Zhaoyang, the deputy director general of China’s Department of Rural Health Management, says the barefoot doctor scheme had a profound influence on the Declaration of Alma-Ata. “WHO research in the 1970s found problems relating to the health-cost burden and unequal distribution of health resources. To try to solve the inequality, it did research in nine countries, including four cooperation centres in China. China’s experience inspired WHO to launch the health for all by 2000 programme.”

Zhang says the barefoot doctor scheme, initiated by central government but largely administered locally, had its origins in the 1950s. “The name barefoot doctor became popular in late 1960s after an editorial in the People’s Daily by Chairman Mao in 1968,” he says. “The name ‘barefoot doctor’ originated in Shanghai because farmers in the south were often barefoot working in the paddy field. But China’s village doctors had been there long before. In 1951, the central government declared basic health care should be provided by health workers and epidemic prevention staff in villages. In 1957, there were already more than 200 000 village doctors across the nation, enabling farmers to receive basic health care at home and work every day. The barefoot doctor scheme was simply the reform of medical education in the 1960s. In areas lacking medicine or doctors, village doctors could go through short-term training – three months, six months, a year – before returning to their villages to farm and practise medicine.”

Zhang says the scheme has evolved over the decades, though the term barefoot doctor is no longer used. “The scheme has never stopped. In the early 1980s, the State Council (the Central People’s Government, the highest executive organ in China) directed that barefoot doctors, after passing an examination, could qualify as a ‘village doctor’. Those who failed would be health workers and practise under the guidance of the village doctors. The village doctors and rural health workers still undertake the most primary health work – prevention, education, maternal and child health care, collecting disease information. The quality of [care provided by] rural doctors keeps increasing in line with social and economic development.”

Dr Liu Xingzhu, the programme director at the Fogarty International Centre at the National Institutes of Health in the USA, was a barefoot doctor from 1975–1977. Aged 19, his senior secondary school classes were interrupted during the Cultural Revolution drive to equip people with practical skills. “The county’s health bureau organized medical training in my school and provided free accommodation and food. The trainers were the best from the county’s central hospital in various fields. Many of the doctors were dispatched from the urban hospitals during the Down to the Countryside Movement (when Mao decreed ‘privileged’ urban youth go to rural areas to learn from workers and farmers) and showed great professionalism. They were very good trainers and doctors.

“After graduating in June 1975, I became a barefoot doctor at the Suliuzhuang commune (in northwestern Shandong Province, south of Beijing) serving 1800 residents. Despite the knowledge I learned from the strict training, the conditions and equipment in the countryside were very limited. I was given only a bag of some basic medicine with two syringes and 10 needles.”

Therein lay both the strength and weakness of the barefoot doctor scheme. It provided the rural poor with health care not known in pre-Revolution days, but the doctors’ limited training, equipment and medical supplies meant they could not do a lot.

Another of the barefoot brigade, Dr Liu Yuzhong, still offers basic health care to his fellow villagers after 43 years’ service. Now 69, he is known by patients as a caring, skilful doctor, though he says, “I learned something of everything, but specialized in nothing.” He adds: “There are great advantages to having a barefoot doctor in the village. The patients are all my neighbours. I know each family’s situation, lifestyle and habits. Since I see my patients very often, even if I cannot diagnose precisely the first time, I can follow up closely and give a better diagnosis the next time.”

When the rural cooperative health-care system was dismantled in the 1980s as a result of China’s economic liberalization, Liu Yuzhong was hired by the local Dingfuzhuang Health Centre on the eastern outskirts of Beijing. “I was lucky because I had passed a Ministry of Health exam in 1981 and acquired the certificate to practise as a village doctor.”

Liu Xingzhu believes health-care services did suffer in the late 1970s and early 1980s when the agricultural sector was privatized. “The barefoot doctors, who were paid collectively by the commune, lost their source of income. Many turned to farming or industry. The most direct effect was that few did inoculations or provided primary health care for the peasants. Many diseases that had been eradicated emerged in the countryside again.”

The user-pays system introduced in China in the 1980s left many out of pocket or unable to afford treatment. The government in recent years has recognized the need to increase health spending and promote new health insurance schemes, a reflection perhaps of China’s special commitment to a primary health care system that “everyone can enjoy, reflects social equality, is affordable for everyone and matches social and economic development,” according to Zhang. Dr Lei Haicho of the Department of Health Policy and Regulation at the Ministry of Health, says the New Rural Cooperative Medical Scheme introduced in 2003 now covers more than 800 million rural residents, while public financing of the health system has increased substantially.

Zhang maintains, however, health-care standards have risen steadily in China, thanks in part to the work of village doctors and health workers, who, he says, receive excellent training and support. “The maternal mortality rate in rural China has decreased from 150 per 100 000 before 1949 to today’s 41.3 per 100 000. The infant mortality rate for the same period has decreased from 200 per 1000 to 18.6. China now has more than 880 000 rural doctors, about 110 000 licensed assistant doctors and 50 000 health workers.” He believes primary health care has also helped reduce poverty in China. “Only with a health body can people undertake education and production activities and improve their living standards. Village doctors have played a significant role in preventing people from becoming impoverished.”

Despite the challenges China faces in providing a modern health-care service to all of its 1.3 billion people, the barefoot doctors and their successors can still show the way to the rest of the world in primary health care, according to Zhang Lingling. Writing in the Young Voices in Research for Health 2007 essay competition sponsored by the Global Forum for Health Research and the Lancet, the doctoral student at the Harvard School of Public Health said: “The impact of barefoot doctors in rural health-care services still exists. Today, both researchers and policy-makers have widely acknowledged it is hard to bring people to work in rural areas. Even the developed countries have experienced a difficult time attracting medical professionals to rural places [so] training local people seems to be the optimal solution [in] building sustainability in rural health-care services.”

Liu Xingzhu also believes the Chinese model can inform other countries’ approach to primary health care. “Chinese experience showed that to promote primary health care, the key issues are human resources and medicine. Chairman Mao advocated there was no need for five years’ training; one year was enough to train a doctor. Short-term training focusing on specific types of work, such as antiviral treatment or prenatal care, is sufficient to meet the demands of primary health care, especially in the countryside or poverty-stricken areas.” ■

http://www.who.int/bulletin/volumes/86/12/08-021208/en/




Three barefoot doctors, part of a production brigade near Shanghai.
  
  
  

 
 
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