Barefoot doctor
Barefoot doctors were healthcare providers who underwent basic medical training and worked in rural villages in China. They included farmers, folk healers, rural healthcare providers, and recent middle or secondary school graduates who received minimal basic medical and paramedical education. Their purpose was to bring healthcare to rural areas where urban-trained doctors would not settle. They promoted basic hygiene, preventive healthcare, and family planning and treated common illnesses. The name comes from southern farmers, who would often work barefoot in the rice paddies, and simultaneously worked as medical practitioners.
In the 1930s, the Rural Reconstruction Movement had pioneered village health workers trained in basic health as part of a coordinated system, and there had been provincial experiments after 1949, but after Mao Zedong's healthcare speech in 1965 the concept was developed and institutionalized. China's health policy began to emphasize the importance of barefoot doctors after Mao Zedong's June 26 directive, and, in 1968, the barefoot doctors program became integrated into national policy. These programs were called "rural cooperative medical systems" and worked to include community participation with the rural provision of health services.
Barefoot doctors became a part of the Cultural Revolution, which also radically diminished the influence of the Ministry of Health, which was filled with Western-trained doctors. Still, barefoot doctors continued to introduce scientific medicine to rural areas by merging it with Chinese medicine. With the onset of market-oriented reforms after the Cultural Revolution, political support for barefoot doctors dissipated, and "health-care crises of peasants substantially increased after the system broke down in the 1980s." Although the official barefoot doctor system came to an end, the legacy of the barefoot doctors inspired the 1978 World Health Organization conference on primary health care and the resulting Alma Ata Declaration.
Background
Leading up to the cultural revolution, China's healthcare system was multifaceted. By Rosenthal's account, after the Rural Reconstruction Movement in the 1930s, efforts in rural healthcare increased, and rural healthcare experiments in 1950s Shanghai began to shape the barefoot doctor policies that were to come. As Gross describes, different medical practitioners filled different roles for rural citizens, who did not have access to the medical elite because those resided mainly in urban centers. In addition, according to Gross, there was conflict between those who were loyal to Chinese medicine and those who accepted scientific medicine, which was slowly being introduced to China.Rural healthcare began to change in 1949, when the People's Republic of China was established. The government began to focus more on healthcare, especially on preventative medicine and incorporating scientific medicine into Chinese medicine. Union clinics, owned by the state but run by the resident doctors, became one way of dealing with the lack of sufficient healthcare in rural areas. However, despite the new attention placed on centralized healthcare and public health, Zhang and Unschuld note that differences between urban and rural public health were still significant. Mao Zedong himself noted the disparity between the quality of urban and rural health
Selected individuals
The initial pool of barefoot doctors required no education or training as they were sourced from healthcare providers already working in rural areas as well as urban doctors. As Gross mentions, an important part of Mao's plan was the movement of sending doctors, to serve in the countryside. Mao pushed for medical school graduates to be sent to work in rural areas, where he felt they could help the rural inhabitants while, as Gross and Fang explain, also redistributing talent from urban to rural areas. They would live in an area for half a year to a year and continue the education of the barefoot doctors. According to Fang's research on Hangzhou Prefecture, many of the urban doctors sent to rural areas were quite unhappy about their fate. In fact, being sent to rural areas was often seen as a punishment because of the lower wages and challenges of rural living. Hesketh and Wei, on the other hand, mention that although some were unhappy, other urban doctors were grateful for the lessons they learned while living as peasants.However, more medical practitioners were necessary, and the state turned to both rural residents and urban ones. These barefoot doctors were usually chosen by members of the commune where the barefoot doctor would then serve. Often, "young farmers" were selected to train to become barefoot doctors. Other barefoot doctors originally worked as folk doctors and retrained to become barefoot doctors after the Cultural Revolution. Some trainees were also recent graduates of middle school. Barefoot doctors were often fairly young, which Fang attributes to the fact that the state wanted them to be able to support rural healthcare for the foreseeable future. Fang also describes that physically weak or disabled people often trained to become barefoot doctors, as the job was much less hard on the body than agricultural labor.
The nature of the barefoot doctor system also allowed women to enter a profession that had previously been dominated by men. Fang explains that, due to tradition, many females felt uncomfortable being examined by male doctors, and, as a result, silently had a host of diseases, especially gynecological ones. However, the barefoot doctor system required that each village have a female doctor. With this push, women's health improved significantly, although Fang mentions that health disparities were still present.
Education and training
The barefoot doctors usually graduated from secondary school and then received three to six months of training at a county or community hospital. As Hesketh and Wei indicate, this training was often provided by medical professionals who had been sent away from their urban homes to work in rural areas. Training was not standardized across the nation, as different areas had different needs. In general, preventative care, vaccinations, and disease identification were skills taught to barefoot doctors-in-training. Thus, duration and curriculum of the training was adjusted to fit the specific needs a region's barefoot doctor was meant to fill. Through this training system, Hesketh and Wei's count indicates that about one million barefoot doctors were prepared to serve in the countryside. Training was focused on epidemic disease prevention,curing simple ailments that were common in the specific area. Barefoot doctors were also trained to use scientific medicines and techniques. Because of this, Fang's research shows that barefoot doctors were often the first to introduce scientific medicine to rural villagers. Through this introduction, scientific medicine existed side by side with Chinese medicine in the rural areas. According to Wang and Gross, this coexistence created a productive and innovative new system that brought together the positive aspects of each because Chinese medicine was much cheaper and required less equipment than scientific medicine. Thus costs were kept down but quality of care was still high because Chinese medicine practitioners had to receive scientific medicine training and scientific medicine practitioners had to receive Chinese medicine training as part of the barefoot doctor program. Literacy inhibited some from becoming barefoot doctors. The training system required students to be literate, and thus illiterate folk doctors were unable to retrain as barefoot doctors. However, for those who were literate, the barefoot doctor training provided a level of education most rural villagers never attained.
Work
Scope of practice
Barefoot doctors acted as primary healthcare providers at the grass-roots level. They were given a set of medicines, both scientific and Chinese, that they would dispense. Often they grew their own herbs in the backyard. Alternatively, practitioners went on herb-collection trips twice a year, which served to replenish the medicinal herb supply in rural areas. Gross describes that herbs provided an inexpensive, easily accessible method for rural healthcare in contrast to the expensive tools used by scientific medicine. As Rosenthal mentions Mao had called for, they tried to integrate both scientific and Chinese medicine, like acupuncture and moxibustion. According to Ots and Fang, not only did the barefoot doctors introduce scientific medicine to rural areas, but they also helped facilitate a resurgence in interest in Chinese medicine. Ots explains that Chinese medicine had previously been pushed away in favor of scientific medicine in elite physician circles. Gross shows that with Mao's June 26 directives, the previously negative attitudes toward Chinese medicine began to shift in favor of appreciating Chinese medicine as a symbol of China's rich culture. An important feature of the barefoot doctor was that they were still involved in farm work. Barefoot doctors often spent as much as 50 percent of their time on farming, which Rosenthal explains meant that the rural farmers perceived them as peers and created a sense of equality between physician and patient. The barefoot doctors were integrated into a system where they could refer seriously ill people to township and county hospitals.Barefoot doctors provided mostly primary healthcare services and focused on prevention rather than treatment. They provided immunizations, delivery for pregnant women, and improvement of sanitation. Health aides provided help and back-up to the barefoot doctors, although they usually spent most of their time as farmers and only 10% of their time helping out. The village hosting the barefoot doctors and health aides funded the materials required for medical care.
The proliferation of barefoot doctors in the early 1970s increased abortion access in rural China. They also had an important role for disseminating information about birth control. Barefoot doctors guides generally contained chapters dedicated to family planning with descriptions of birth control techniques, IUDs, oral birth control, and the rhythm method. Such guides varied significantly by region in which they were published.