When the Communists founded the PRC in early October, 1949, they established control of one of the most impoverished nations on earth. After a century of domination by Europeans, the fall of the Qing Empire was followed by partial Japanese occupation and a 38-year civil war. The vast majority of the population were engaged in subsistence agriculture, and a survey on the causes of death conducted in 1929-31 revealed that more than half of all deaths were caused by infectious diseases. A list of leading health problems before 1949 () is noteworthy for the virtual absence of non-communicable diseases (King and Locke, 1983 as cited in ref. 1), and rural health care was in very poor supply (4-6).
Major health problems in China before 1949*
Early disease-control programs
The political turmoil and slow socioeconomic development in China between 1949 and 1978 obscure its impressive progress in population health during those years. The Communists were quick to make good on promises of land-reform and establishment of a national “people’s” government. In 1950 a Marriage Law was enacted, providing equal rights for women, and the first National Health Congress established a focus on rural health, disease prevention through campaigns, and collaboration between western and traditional Chinese medicine. The focus on improving rural health and on CDC persisted until the 1980s.
Early efforts in public health included work on vaccination, environmental sanitation and hygiene (including the early introduction of composting of night-soil to reduce the concentration of intestinal parasites) and the development of organized CDC programs. Incredibly, between 1950 and 1952, over 512 million of China’s
600 million people were vaccinated against smallpox, massively reducing case numbers; the last outbreak of smallpox in China occurred in 1960, 20 years before global eradication (7). By 1957, more than two-thirds of China’s then
2050 counties had an epidemic prevention station (EPS) or more specialized centres for the control of specific diseases (such as malaria, plague, schistosomiasis, leishmaniasis and brucellosis) modelled on those established in the Soviet Union earlier in the 20th century. Their efforts included “patriotic health campaigns” focusing on ensuring a clean environment and safe drinking water, vector control, latrine construction and human waste disposal. Each of these short-term interventions (on average twice a year, lasting for around a week) required the mass mobilization of peasants, and so served to increase the “health literacy” of the rural population (1,6-8).
Apart from targeted vaccination, other nascent disease control programs emerged. As a result, cases of typhus dropped by 95% in the 1950s, and there were also major attempts to control gonorrhoea and syphilis (considered by the communists to be social diseases associated with liberal western attitudes and affecting up to 50% of some population groups), first with imported and then domestically produced penicillin. Prostitution was also outlawed and the status of women elevated (6,9-11). Vaccination and campaigns against diphtheria and tuberculosis (TB) also commenced in the 1950s. In the late 1950s, another campaign to “exterminate the four pests” (sparrows, rats, flies and mosquitoes) was avidly implemented, albeit with major negative results when the exploding locust population decimated crop harvests, contributing to famine from 1958-1960 (1,7).
Newborn and puerperal infection rates also decreased tremendously during this period, with the re-training of up to 750
000 traditional midwives and establishment of 2380 maternal and child health (MCH) centres by 1952. No other type of medical facility increased at this rate, and a major result was the decline in neonatal tetanus, down from up to 5% of all newborns to a fraction of this Figure (1,6.
Whilst tremendously successful, these mostly preventive care efforts, however, do not infer that rural Chinese had access to clinical care in the 1950s. Patriotic health campaigns were highly effective in CDC but were rarely sustained for more than a month; diseases not addressed by the campaigns were simply neglected and curative care was virtually unavailable outside the cities. Medical schools primarily trained doctors for hospital work. Rural Chinese basically only had access to Chinese herbal medicine and other traditional healers until well into the 1960s (1,6).
In addition, the patriotic health campaigns occurred in the context of major political instability in China. After liberation of the masses in 1949 and a period of relative self-control by peasants of their newly acquired land and produce, Mao introduced a set of disastrous social and economic policies involving community and agricultural collectivization. Motivated by jealousy of the Soviet Union and the west and his perspectives that the rural masses should be both self-sufficient and the source of grain for the cities, Mao promoted the Great Leap Forward from 1958-1960. This included new cultivation methods that failed dismally, further reducing the harvest. Impacted also by adverse weather and the locusts, the resulting famine resulted in the death by starvation of tens of millions, temporarily halting the rapid population growth wrought by successes in CDC.
Village doctors bring curative care, knowledge and a public health approach to the masses
After the disastrous Great Leap period, Mao retreated into the political background and China entered a period of relative political quiet in the early 1960s. Collectivization was relaxed and the patriotic health campaigns continued. EPSs grew in number, reaching around 2500 by 1965 (7), and vertical CDC programs expanded. With a return to food security (albeit with rationing), population growth resumed and life expectancy continued to grow (1). However, unhappy with his perception that the revolution was faltering, development was slowing and that his own political star was fading, in 1966 Mao launched the Cultural Revolution, throwing China into a ten-year period of political and economic chaos. The Revolution was characterized by mass mobilization of urban youth against authority, closure of higher education institutions and a “return to the countryside” policy to pursue revolution as an abstract concept (6).
One positive element of this period, however, was the establishment of a village level cooperative medical scheme (CMS) managed by “barefoot doctors”, a new cadre of community-level health worker who brought basic curative care, health education and a continuous rather than campaign-style public health approach to rural peasants (12). Later hailed as the foundation of primary health care (13), China’s barefoot doctors rose in number from around one million in 1970 to a peak of around 1.8 million in 1977. Many barefoot doctors were selected from, functioned in the context of and were largely funded by local production brigades (roughly 1000-2000 people in a geographic area) or teams (200-400 people). These brigades had replaced the failed, larger communes established during the Great Leap years, and apart from their commitment to providing grain to the national coffers at fixed prices, were semi-autonomous. Other barefoot doctors were selected from among the urban youths who were “sent down” to the countryside, ill-equipped to farm but educated and literate enough to be trained in basic health care. As a result, and also because each brigade had variable financial capacity to fund its CMS, the quality of health care provided by the barefoot doctors (and an even more basic cadre of community health worker, the health aide, whose numbers added an additional 3.7 million to the community health workforce in 1970) varied widely (). It also depended on the level and quality of training (which varied from one to six months in duration) and supervision. Some villages also benefited from physicians who had been sent down from the cities for ideological re-education but continued to provide health care, and also from oversight by the EPS team at county level (6,12,14).
The rural government and health system in 1960s–1970s China, depicting the three-tier network.
The roles of the barefoot doctors and health aides included environmental sanitation, health education, disease screening, surveillance and control, basic clinical care or referral and family planning. CDC continued to benefit from management of water sources and disposal of human excreta (including through composting), improvements in wells, toilets, stables, cooking areas and the local environment, and specific disease control programs through reducing stagnant water, spraying and other measures to control flies, fleas and mosquitoes. Although the barefoot doctors continued the “prevention first” approach to CDC established in the 1950s under the guidance of the Patriotic Health Campaign Coordination Office (a quasi-Ministerial agency only absorbed into the Ministry of Health in 1989), clinical links were established via a three-tier referral network from village through commune to county levels, with supervision in the reverse direction. This three-tier network persists today (7,15,16).
Although politically inseparable from the prevailing harsh limitations on personal expression and movement (6), CDC in China in the late 1960s and throughout the 1970s thus benefited from a large cohort of community-level staff (health aides, barefoot doctors, sent-down physicians and also midwives) with a basic knowledge of health and hygiene (14). These cadres continued the “serve the people” philosophy of the patriotic campaigns initiated in the 1950s, but with a bottom-up rather than top-down approach (4) and, along with other determinants, especially education, contributed in a highly cost-effective way to the continually plummeting crude death and child mortality rates, rising life expectancy and to CDC in rural China.
Perspectives on the origin of China’s village doctors
The rationale for the introduction of the barefoot doctors, and their impact, has interested recent scholars, and the different perspectives are summarized in . One thesis holds that they were part of Mao’s goal of improving the level of literacy in China, itself the antithesis of the contemporary philosophy that education was bourgeois (17). In support of this theory is the observation that improvements in education complemented the public health campaigns in reducing mortality (8). Another points to three influences: (i) models provided by Guomindang experiments on basic primary health care in the 1930s and 1940s, and the Soviet ‘feldshers’ (field doctors who provided primary health care at village level, supervised by trained staff at higher levels); (ii) the ideology of self-sufficiency, gender equality and egalitarianism (with the peasants as the agents, not just the beneficiaries of revolution), taken up by the Mao and the Communists in Yan’an in the 1940s (also giving rise to the preference for the traditional Chinese medicine practiced by barefoot doctors) and (iii) the political situation in the mid-1960s, which gave rise to Mao’s contention that the urban elite (including the Ministry of Health) was ignoring the backbone of the Revolution, the rural peasantry (18), and undermining his reliance on them for his own status. Having failed at commune level during the Great Leap years, self-sufficiency was instead introduced at the more stable village or brigade level, represented in the health sector by the barefoot doctors and the CMS. Whilst benefiting the health status of the population, the benefit for the nation as a whole through collectivization at this lower level was the resulting reliable supply of grain for the cities (6).
Origins and determinants of China’s barefoot doctors program (after Bien, 2008; ref 6).
Another feature of this period that facilitated the success of the barefoot doctor movement was the surfeit of labour generated by the burgeoning population, movement restrictions that kept the rural population above 80% of the total until 1979 and the relocation of educated urban dwellers to the countryside. Sent-down physicians and urban-educated barefoot doctors made the most of the relative physical ease and prestige of their work, and the fact that income was somewhat less dependent on state-controlled grain prices (6,14).
Finally, the focus on gender equity was another significant influence on the success of the barefoot doctor movement. Although only one third of officially designated barefoot doctors were female, women made up the majority of midwives and health aides, who also functioned as barefoot doctors and contributed to CDC. Ideologies promoting female participation in the rural labour force provided the barefoot doctors program with a significant source of labour, also contributing to effective MCH programs (6).
Along with various social determinants, particularly education and the emancipation of women, the outcome of the PRC’s efforts in CDC and community-funded public health during its first 30 years are remarkable indeed, considering its relatively poor economic progress. A 1984 World Bank report suggests China was already entering the epidemiologic transition in the mid-1970s, with deaths due to communicable disease down to only 25%, compared to 44% in other low income countries and virtually all deaths before 1949 (3). Other reports document an increase in life expectancy from 35 to 68 years, a fall in the crude mortality rate of around 66% and infant mortality from around 250 to 40 deaths per 1000 live births and a decrease in malaria prevalence from 5.5 to 0.3% of the population, between 1949 and 1981 (7,14).