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

During the decade-long Cultural Revolution from 1966 to 1976, rural China experienced a remarkable improvement in public health conditions despite the nationwide political chaos. This improvement, according to author Xiaoping Fang, is attributed to the “barefoot doctor (chijiao yisheng) program” — a radical system of health-care delivery for the rural masses officially endorsed in 1968. The centrepiece of this program was the introduction of “barefoot doctors” into Chinese villages. The barefoot doctors, defined officially by the People’s Daily in 1968, “were young commune members who were selected to receive basic medical training and then returned to their brigades to serve their villages” (p. 30). The term “barefoot (chijiao)” addresses both the doctors’ peasant-class origin and their socialist revolutionary passion. With the implementation of rural-reform policies and the dismantling of the people’s commune system after 1978, the barefoot doctor program began to gradually disintegrate. Barefoot doctors who passed medical examinations and continued practicing medicine in villages were then renamed “village doctors.”

Fang provides a reliable and comprehensive account of the barefoot doctor movement and its significant impact on the contestation between Chinese and Western medicine, the evolution of rural China’s health-care system, and the formation of a new professional group. The greatest strength of this book is the author’s effort to challenge the orthodox interpretation of the barefoot doctors’ role in the contest between Chinese and Western medicine in the village arena. Employing evidence from local archives of the Cultural Revolution period and personal interviews with villagers and former barefoot doctors in the seven counties in eastern China, Fang closely examines a shifting constellation of factors including knowledge transmission, pharmaceutical prices and supply chains, healing styles, and medical beliefs. Fang argues against the portrayal of barefoot doctors as a revolutionary vanguard, a perspective championed by the prevailing government propaganda. He argues alternatively that the barefoot doctors were more effective in “facilitating the entry of Western medicine into villages hitherto dominated by Chinese medicine through scientificization, institutionalization, and professionalization” (p. 3), which consequently led to the marginalization of traditional Chinese medicine and practice. In this sense, Fang concludes, “the barefoot doctors program lasted from 1968 to 1983, [and] was a pivotal stage in the displacement of Chinese medicine by Western medicine in rural China” (p. 181).

This book sheds light on the ongoing debate over the crisis of China’s rural medical system in the post-socialist era. Looking beyond the present nostalgia-driven scholarship on public health in China, Fang discards the negative assessments that attribute the deteriorated health-care condition in villages to the reforms initiated in 1978 and the disintegration of the barefoot doctor program in the 1980s. Instead, he argues, “the reforms consolidated the position of barefoot doctors as a result of their further professionalization as ‘village doctors’… and guaranteed a remarkable continuity in medical and public health provision, even though rural Chinese still face serious challenges in accessing health-care services” (p. 3). Fang identifies this crisis as an inevitable outcome of the problematic structure of the three-tier rural medical system established at the end of 1960s, which was comprised of county hospitals, commune clinics, and barefoot doctors’ medical stations at brigade levels. Due to the growing professionalization of the barefoot doctor group, their advantages in expanding Western medicines, and the development of the referral system, the second tier — the commune clinics that were previously dominated by Chinese medicine practitioners — became largely redundant and finally collapsed in the late 1970s. The three-tier system gradually took on a dumbbell-shaped structure: the middle part (commune clinics) shrank, while the top and bottom (county hospitals and brigade medical stations) grew in importance. This unbalanced hierarchical structure, Fang points out, eventually led to the reduced accessibility, affordability, and equity of public health care in rural China.

Fang cites plenty of statistic and oral evidence to demonstrate the rise of Western medicine to dominance and the marginalization of...