Barefoot Doctors and Western Medicine in China is the first critical, book-length account of China’s barefoot doctor programme available in English. In the 1970s, the World Bank and representatives from other Western institutions endorsed China’s rural Cooperative Medical System (CMS), with 1.8 million barefoot doctors at its base, as a model for other developing countries to follow. Scholars have bemoaned the decline in the 1980s of that system for ushering in a new age of health inequality in which both catastrophic and chronic illness can lead to impoverishment. Fang is a medical historian. However, his book is a village-based ethnography, which draws upon interviews with former barefoot doctors and their patients, as well as government archives, local gazetteers, and periodicals, to examine the rise and decline of the barefoot doctor system in one village.
Fang’s analysis has a three-fold purpose. First, he intends to correct the notion that barefoot doctors allowed Chinese medicine to maintain equal footing when faced with the arrival of Western medicine, as Chinese government propaganda argued. Instead, Fang’s primary argument is that barefoot doctors created a preference for Western medicine. Second, while much of the literature on China’s CMS emphasises the three-tiered structure of this system, Fang argues that attention to barefoot doctors caused neglect of the middle-level commune clinics, resulting in a top- and bottom-heavy structure he describes as a ‘dumbbell shape’. Finally, in contrast to numerous accounts that bemoan the collapse of the rural health system in the 1980s, Fang argues that the ‘village doctor’ credentialing system consolidated the position of former barefoot doctors and allowed for the continuity of medical care in the 1980s.
In chapter 1, Fang chronicles the transformation in the 1950s of a formerly private medical clinic located in rural Zhejiang province, near Hangzhou, into the Jiang Village Union Clinic. Fang argues that the birth of the union clinics, including selection of villagers to become health workers during the agricultural collectivisation process, represented a ‘downward extension of the state medical system’ (p. 27). Fang argues that despite the fact that many of the union clinics, which were in place before 1960, would later become commune clinics, the union clinic structure did not correct the unequal distribution of health resources between urban areas and the countryside. This inequality gained attention in 1965 and would subsequently be partially corrected by sending urban medical professionals to the countryside to help train armies of barefoot doctors.
Fang then devotes chapters 2 and 4 to the argument that barefoot doctors privileged Western medicine, rather than reconciling Western and Chinese medicine. In chapter 2, Fang introduces the new selection criteria and training programmes that caused reproduction of medical knowledge in the countryside to transform from being a family matter to one with an emphasis on serving the people. In chapters 3 and 4, Fang introduces quantitative data on both declining mortality rates from notifiable infectious diseases and rising expenditures and consumption of pharmaceuticals to support his argument about the increasing role of Western medicine. Fang concludes that it is ironic that barefoot doctors faded away as a result of the Western medicine that they themselves introduced into rural China.
In chapters 5 and 6, Fang turns to his final two arguments. In chapter 5, he explores how the creation of the barefoot doctor system allowed for the systemization of rural residents’ interactions with medical personnel. In this chapter’s conclusion, Fang also turns to the argument that attention to barefoot doctors resulted in a dumbbell-shaped structure in the rural health system because commune clinics lacked equipment, supplies, and personnel. In chapter 6, Fang looks at how the barefoot doctor’s identity as rural health provider was created through training programmes and was negotiated with those they served. This final chapter also serves as the basis for his third argument that the addition of tests to credential ‘village doctors’ allowed for continuity in the Jiang Village health system.
Some of the most convincing evidence Fang uses to support his primary argument that barefoot doctors created a preference for Western medicine came from interviews with former barefoot doctors and their patients. Fang’s interviewees note that Chinese medicine takes a long time to master and to take effect in the body. By contrast, Western medicine could be learned by anyone with basic literacy skills and could cure illnesses quickly. Throughout the book, Fang supplements his rich interview data with archival evidence.
Fang’s final argument about the continuity of care in Jiang Village raises a question relevant to provision of health services in rural China. Was the professionalization he found in wealthy Zhejiang also true of poorer interior provinces? Like other scholars, Fang found that several Jiang Village barefoot doctors abandoned rural health work for more lucrative professions; at the same time, Fang found that the reduction in the number of barefoot doctors did not result in the closure of the majority of rural health stations. But was this continuity true elsewhere in China? Certainly, these questions cannot be answered in a case study of a single village. Fang has provided a rich ethnographic account of what happened in one village; it remains for other scholars to investigate the extent to which Fang’s findings reflect the experience across China more generally.
These questions have implications for rural health policy in the near future. As scholars begin to evaluate China’s New Rural Cooperative Medical System (NRCMS), which was put in place in most provinces between 2003 and 2008, assessing whether rural health services can adequately provide care to hundreds of millions of peasants covered under the NRCMS will be an area for further evaluation. Finding professionally trained personnel to serve in remote rural regions is not only a problem in China; it arises in developing and developed countries alike.
Fang’s account is the first sustained look at the creation and decline of one union clinic over several decades, as well as the rise and decline of the barefoot doctor system in one rural county. His book adeptly shows that the relationship between Chinese and Western medicine was dynamic and negotiated. Fang also shows how the decline of the barefoot doctor system, which had helped to institutionalize the new practice of seeing doctors in clinics rather than the home, ultimately ushered in the return of medicine in a pluralistic form, including folk medicine practices and religious rituals. The book will appeal to students, scholars, and practitioners interested in comparative health systems, and particularly to individuals interested in understanding the transformation of a medical system.