Barefoot Doctors and Western Medicine in China by Xiaoping Fang (review)

In the 1970s, China’s barefoot doctors became one of the public health showpieces of the century, lauded by the World Health Organization as a model for medical service in developing countries and engendering the primary health care movement. Until now, however, there has been no singular study of barefoot doctors available in English. Xiaoping Fang aptly fills this historical gap with a social history that combines local archival research with an ethnographic study of barefoot doctors from seven counties in prosperous Hangzhou prefecture, Zhejiang province.

Fang’s three primary arguments contend with popular conceptions of barefoot doctors. First, Fang argues that barefoot doctors were not the vanguard of traditional Chinese medical knowledge, as government propaganda has asserted. Instead, and this is his most forceful point, the barefoot doctors were responsible for introducing Western biomedicine into the countryside, effectively marginalizing traditional healing methods as well as traditional healers themselves. Western medicine was relatively easy to learn for the semiliterate health workers trained in the barefoot doctors’ basic medical techniques. Barefoot doctors were especially effective in treating infectious and helminthic diseases with Western pharmaceuticals. Rather than studying the intricate theoretics of Chinese medicine, barefoot doctors needed only to read the labels on the Western pharmaceutical bottles and administer the drugs. The barefoot doctors also undertook public health initiatives, for example family planning, schistosomiasis eradication, and vaccination campaigns, which further spread ideas of Western biomedicine throughout the countryside. Rural Chinese began to expect an injection or brief antibiotic course instead of a long treatment with inconvenient and bulky herbal preparations, leading to a continued preference for Western medicines.

Fang’s second argument is that barefoot doctors were crucial to the institutionalization of medicine in China. They lived among the villagers, spoke the local dialect, and were integral members of their communities. Barefoot doctors thus served as intermediaries between the rural villagers and the higher levels of the medical system, easing the transition from home-based to clinic- and hospitalbased care. The success of the PRC’s medical system rested on the backs of the barefoot doctors, yet Fang presents a twist. The government constructed a threetiered medical hierarchy (brigade, commune, and county), with each level responsible for more sophisticated delivery of medical care. Barefoot doctors provided the lowest level of treatment at the brigade level. But rather than the official three tiers, Fang uncovers a bell-shaped structure that effectively shrank the middle-tier commune services, since barefoot doctors referred their patients directly from brigade clinic to county hospital, bypassing the commune level altogether. The barefoot doctors impacted the very makeup of the Chinese medical system.

Finally, Fang demonstrates that barefoot doctors were fundamental to the professionalization of medical care in China. Whereas traditional Chinese medical knowledge was acquired through generational or apprenticed transmission, barefoot doctors underwent official training and licensing programs. Medical texts written for the novice increased the number of people who could access medical knowledge, and standardized medical training reduced the urban–rural medical gap. Government salaries, subsidies, and reimbursements limited competition for patients. Barefoot doctors gained a new socialist identity as they implemented public health interventions and shared information, creating a professional cadre of health care workers who were respected in their communities.

The dismantling of the rural medical system in the 1980s, in which many barefoot doctors transitioned into private practice, created serious disruptions in quality and access of care. This privatization, coupled with the rudimentary training of the barefoot doctors and lack of health education for the populace, also created significant overutilization of Western techniques such as parenteral delivery of medications and caesarian births. Furthermore, the move in the 1980s to streamline healthcare access and quality by integrating pharmacies with clinics and hospitals has led to problematic overprescription of antibiotics and other drugs. Fang’s brief analysis of these issues should serve as a foundational framework for further research on contemporary public health issues. Yet his distinct lack of citations...