The barefoot doctor: the political incarnation of the village doctor

  China News Weekly reporter/Li Mingzi

  Issued in 2021.11.8, Issue 1019 of "China News Weekly"

  In the 54 years of practicing medicine in rural areas, Ma Wenfang is still used to be called "barefoot doctor" by villagers, although this title has been officially cancelled since 1985.

  The name "barefoot doctor" first appeared in the People's Commune in the last century.

In the summer of 1968, the "Red Flag" magazine sponsored by the Central Committee of the Communist Party of China published "The Direction of the Medical Education Revolution from the Growth of "Barefoot Doctors"-Shanghai Investigation Report".

At the beginning of the article, it said, "'Barefoot Doctor' is the affectionate name of the poor and lower-middle peasants in the suburbs of Shanghai for the half-medical and half-agricultural hygienists."

  This article was subsequently approved by Mao Zedong and was published in the People's Daily on September 14 of the same year. The "Barefoot Doctor" quickly became a hot topic of public opinion at that time.

Barefoot doctors everywhere have naturally become the "typical" reported by the media-"the cowherd baby of the old society" who relies on "a red heart for the great leader" to study medicine assiduously and treat intractable diseases for the poor and lower-middle peasants.

The image of the barefoot doctor was painted into propaganda posters, comic strips, and even printed on stamps, food stamps and calendars, becoming a vivid symbol of that era.

  For Ma Wenfang, a village doctor in Suliuzhuang Village, Dagang Li Township, Tongxu County, Henan Province, aside from the aura of this group in a special era, the greatest contribution of barefoot doctors is to provide farmers with the most basic health protection.

At that time, the barefoot doctor wore a straw hat on his head and carried a medicine box on his back.

When malaria was prevalent, it was these barefoot doctors who asked for consultations from house to house, "delivering the medicine to the hand, taking the medicine to the mouth, and not swallowing it," and finally eliminated the malaria.

  The UN Women and Children’s Fund concluded in its 1980-1981 annual report: China’s "barefoot doctor" model provided primary care for backward rural areas and provided a model for underdeveloped countries to improve the level of medical and health care.

  After the 1980s, the people's commune system collapsed, and the barefoot doctor system based on it also disappeared.

The book "From Barefoot Doctors to Village Doctors" records that although the form of medical services in rural areas has continued to change since then, the main staff of rural doctors is still the barefoot doctors of the year.

Many of them have been working until today in the 21st century.

The birth of a rural political star

  "In the 1950s and 1960s, there were no doctors in our village." Ma Wenfang recalled to China News Weekly. At that time, large communes had hospitals, and small communes did not even have clinics. Some small communes may have old people. Chinese medicine.

At that time, the common people generally did not have money to buy medicine. If the farmers had a fever or a cold, they would eat a handful of corn, drink a bowl of hot water, go home and get covered in a blanket and sweat all over. From the hospital, I had to go home and wait for death.

  Lack of doctors and medicines was a common situation at that time, and in rural areas with poorer economic conditions, doctors and medicines were even more in short supply.

According to statistics, in 1964, 69% of senior health technicians nationwide were in cities and 31% were in rural areas, of which only 10% were below the county level.

The population distribution at that time was just the opposite. The urban population only accounted for 1/10, and over 90% of the population lived in rural areas.

  Ma Wenfang's mother died of typhoid fever in the 1960s, and she was only 32 years old.

Five days after his mother's death, his 8-year-old brother contracted a cold.

The child was skinny and skinny, because there was no doctor and no medicine, and he was unconscious within a few days of illness.

Nearby folks donated 1 cent and 2 cents to save 169 yuan, and then took Ma Wenfang's brother to the Kaifeng People's Hospital for treatment. Five days later, he died.

  "In less than two months, there were two lives in my family. At that time, I knelt down to the graveyard and vowed that I would become a doctor and treat the fellow villagers and repay the favor." Ma Wenfang recalled.

  At that time, a new rural health care system was being explored.

In August 1950, the first National Health Conference was held, and for rural health care, the idea of ​​“establishing health centers in counties, district health centers, administrative village health committees, and natural village health workers” was proposed for rural health care.

While strengthening the construction of rural grassroots health institutions, it also organized medical staff to go to the countryside to support rural grassroots.

  In January 1965, Mao Zedong approved and forwarded the "Report on Rural Issues in the Organization of Mobile Medical Teams" from the Party Group of the Ministry of Health to the Central Committee.

Taking this instruction as a major political task, all localities quickly organized medical teams to rural, forest, and pastoral areas for roving medical treatment.

Thoracic surgeon Huang Jiasi, pediatrician Zhou Huakang, and gynecologist Lin Qiaozhi all participated in the itinerant medical treatment.

  In this regard, Yang Nianqun, a professor at the Qing History Institute of Renmin University of China, pointed out in his article "Epidemic Prevention Behavior and Space Politics" that for a long time after liberation, medical personnel only visited rural areas in the form of rescue teams from time to time, and were unable to visit the countryside. The vast rural areas have formed a relatively institutionalized diagnosis, treatment and epidemic prevention network.

  On June 26, 1965, after listening to the work report of the Ministry of Health, Mao Zedong said: “The work of the Ministry of Health only serves 15% of the population of the country, and this 15% is mainly the master. The majority of farmers do not receive medical treatment. There is no medicine and no medicine. The Ministry of Health is not the people’s Ministry of Health. It should be changed to the Urban Ministry of Health or the Master of Health, or the Urban Master of Health!” Mao Zedong instructed: “The focus of medical and health work should be placed in the rural areas! "Cultivate a large number of doctors who are'affordable in rural areas', and they will provide medical services for farmers."

  This passage was later called the "June 26 Directive."

On September 1 of the same year, the "People's Daily" published an editorial on the front page of the headline entitled "Effectively Put the Focus of Medical and Health Work in the Rural Areas".

The term "barefoot doctor" was not mentioned at that time.

  Shanghai took the lead in pilot projects.

In the summer of 1965, the Jiangzhen Commune in Chuansha County, Shanghai started to run a training course. Huang Yuxiang, who graduated from Suzhou Medical College, was a teacher to teach common medical knowledge and simple treatment methods. The trainees returned to the commune as a health worker after studying in the crash course for 4 months.

Wang Guizhen, who was later called "the first Chinese barefoot doctor", was one of the first batch of students in this training class.

  Wang and Huang used the method of "combination of land and foreign countries" to save money for local villagers to see a doctor. They also had to go to the fields to farm and work daily. The name "barefoot doctor" became popular among the villagers without knowing it.

In 1968, Shanghai's "Wen Wei Po" published a report on Wang and Huang-"Seeing the direction of the medical education revolution from the growth of "barefoot doctors"."

This article was subsequently reprinted in full by "Red Flag" magazine and "People's Daily".

  Due to the urgent need for medical resources in rural areas and the political background personally instructed by the top leaders during the special period, the "barefoot doctor" system was quickly promoted nationwide.

According to the "Report of the Ministry of Health on the National Working Conference of Barefoot Doctors" at that time, by the end of 1975, the number of "barefoot doctors" in rural China had reached more than 1.5 million, and there were more than 3.9 million hygienists and birth attendants in production teams.

  "Class composition" and "ideological awareness" are the primary criteria for selecting barefoot doctors.

An article from Xinhua News Agency published on the 5th edition of the People’s Daily on June 23, 1969: “The trainees were recommended by the poor and lower-middle peasants and approved by the Commune Revolutionary Committee. The children of the poor, lower and middle peasants are sent to the training class; the living expenses of the trainees are borne by the brigade.

  In 1967, Ma Wenfang, who had completed junior high school, was selected by the brigade as a "barefoot doctor" to study in the commune training class for one year.

According to Ma Wenfang's recollection, he had to learn anatomy, physiology, and diagnostics of Western medicine, Chinese herbal medicine, and acupuncture. Students had no textbooks, only single-page materials printed by mimeographs.

  Being a barefoot doctor is easier to earn more work points than ordinary villagers.

According to Ma Wenfang's recollection, there was no wage in the people's commune, and they were all earning work points.

In Ma Wenfang's brigade, according to the content and quantity of labor, each person can get 10 points per day, or as little as five or six points per day. Being a barefoot doctor can be regarded as "full attendance", with 280 points per month.

  At that time, the rural areas adopted cooperative medical care, and the primary medical expenses were coordinated by the production brigade.

The brigade where Ma Wenfang belongs, each handed in 1 dime a month, and the brigade is responsible for the rest.

Thanks to the support of the collective economy, farmers can enjoy the most basic medical and health care requirements for a very small fee.

The article "Analysis of the Reasons for the Success of Rural Medical Cooperation in the People’s Commune Period" pointed out that “the existence of the people’s commune system ensures the low-cost operation of the rural cooperative medical system. The rural health website composed of hospitals covers almost all villages in the country."

  Yang Nianqun pointed out that until the barefoot doctor system was established, the upper-level medical administration's instructions, such as vaccination, vaccination, and distribution of anti-epidemic drugs, were truly implemented, and the prohibitions were quickly abnormal.

  The writer Zhu Yong noticed a very interesting phenomenon. In all contemporary art works, barefoot doctors almost coincidentally appear as young girls.

He wrote in "The Fate of Illness in Revolution: A Saint-like Description of Barefoot Doctors" that in reality, an old Chinese medicine image will give patients a sense of trust, but art is different. The artist subconsciously gives barefoot. Doctors "function of the goddess in European classical paintings", the barefoot doctors in the image of young girls interpret life not only from their profession, but also from their bodies.

  Barefoot Doctor became a political star of that era, not only had the opportunity to participate in the National Day military parade, but also became the protagonist in a political propaganda movie.

The protagonist of the movie "Chunmiao" is based on the barefoot doctor Wang Guizhen. In addition to his real medical experience, the movie's protagonist Tian Chunmiao was also given a "political task."

Tian Chunmiao is different from the “institutional doctor” who “cares only about cutting-edge issues, regardless of whether the poor and the middle peasants live or die.” She not only cares about the proletariat, but also has first-class medical services. Successfully joined the fight against the dean of the health center.

Limited medical coverage

  "Because the barefoot doctors have limited professional medical skills, the medical problems they can actually solve are limited. It can only be said that under the conditions at the time, barefoot doctors provided the grassroots with a kind of help within their ability." Peking University Health Science Center Zhang Daqing, director of the Department of History and Medical Philosophy, analyzed the "China News Weekly".

  Ma Wenfang also said that barefoot doctors mainly deal with common diseases such as headaches, brain fever and bronchitis. If they encounter diseases that require surgery such as acute appendicitis, they need to be transferred to a higher-level hospital as soon as possible.

Daily work is to work on the ground with a medicine box on his back, which contains acupuncture needles, common medicines and the "oldest three", that is, a stethoscope, a blood pressure monitor, and a thermometer.

In the summer, whoever worked in the field suffered heatstroke, Ma Wenfang immediately went over to relieve the heat; if someone bumped and scratched, he would go to disinfect and bandage; when the cotton field was sprayed with pesticides, people were often poisoned by inhalation of pesticides, and later on. Anyone who commits suicide by drinking pesticide must go to a barefoot doctor for first aid.

  The book "Creation and Reconstruction—The Research on the Rural Cooperative Medical System and the Barefoot Doctor Phenomenon in the Collectivization Period" concluded that by the mid-1960s, due to continuous learning, practice and training, health care workers (later barefoot doctors) had mastered how many The treatment of ten common diseases, the use of dozens of drugs, as well as acupuncture and simple knowledge of Chinese herbal medicine.

  At that time, medicines were still in short supply and the prices were high.

Farmers spend two cents on two aspirin only when they have a severe cold, and if it still can't be cured, add a penicillin.

Ma Wenfang remembered very clearly that the purchase price of a penicillin was 18 cents, and the selling price was 18 cents, the same price across the country.

  "At that time, everyone was earning work points, and no one had the concept of making money." Ma Wenfang explained that the medicine was bought by the Murakami brigade with money, and the income went to the public.

At that time, it was a planned economy. There was no way to buy more precious antibiotics like penicillin. Each brigade in each village received a maximum of 10 antibiotics per month.

  Zhang Daqing believes that barefoot doctors have played a positive role in the modernization of drugs in rural areas.

As for the "barefoot doctors aggravating the problem of antibiotic abuse" mentioned in some studies, Zhang Daqing believes that this is a kind of "hindsight." , So it is not appropriate to go into it.

  Under the conditions at the time, there were only a few farmers who could afford western medicine. Most villagers relied on the "three soil and four self" for medical treatment, that is, native medicine, earthwork, and native medicine.

Ma Wenfang also bought medicine mills, crushed the herbs into powder, or added water to form pills.

  According to a report by the People’s Daily on February 14, 1969, by the "barefoot doctor" Li Rongyu of the Gaowang Brigade of Qibao Commune, Xinhui County, Guangdong Province, the Qibao Commune where Li Rongyu was located was located in the Pearl River Delta. There were no mountains nearby, and the commune did not grow Chinese herbs. , He went to collect medicine in the mountains dozens of miles away.

  Zhang Kaining, director of the Health Research Institute of Kunming Medical College, believes that the widespread use of Chinese herbal medicine by barefoot doctors in those days has consolidated the rural cooperative medical system.

Chinese herbal medicine is convenient and easy to obtain, economical and cheap, and there are traditions and habit of using them in rural areas.

The use of Chinese herbal medicine not only reduces the economic burden of farmers, but also greatly reduces the expenditure of the cooperative medical fund.

  "At that time, I was brave, but now I can't do it anymore. One is that patients don't recognize or not eat (earth), and the other is that doctors also violate the law." Ma Wenfang recalled that the emergence of barefoot doctors in those days changed the predicament of lack of doctors and medicines in the countryside. Otherwise, the common people could only go home and wait for death when they got sick, so at that time there were almost no cases of patients making trouble or sue doctors. This is also the trust of the patients that the barefoot doctors "come in the wind and go in the rain" hard work.

  At that time, the rural dirt roads were rugged and there were no bicycles, so all visits to villagers' homes were on foot.

Once Ma Wenfang went out to see a doctor for someone else, just in time for his wife to give birth at home. When he came back later, his wife and children were gone. Even now, when he wants to come, Ma Wenfang still feels very guilty to his family.

  "Barefoot doctors have a very distinctive class identity. In the screening process, they can only come from the class classified as'poor, lower and middle peasants'. Because of their poor background, the mind of barefoot doctors is full of moral salvation and has a strong sense of salvation. Love, hatred and emotional inclinations. This kind of emotion also determines the choice of medical treatment objects, which can only be people who are consistent with their class attributes. Their class attributes also determine that they will be'selfless' in the treatment process. Character." Yang Nianqun concluded in "Recreating "Patients"-Space Politics under the Conflict between Chinese and Western Medicine."

  It is precisely because of the class status of "poor, lower and middle peasants" that barefoot doctors perfectly meet the requirements of "a doctor that farmers can afford, use, and keep."

However, the image of barefoot doctors is different from that of rural doctors or "witch doctors" in the past. They are positioned and arranged in an institutionalized political atmosphere.

Yang Nianqun believes that "under the dual discipline of institutional arrangements and human relations networks, barefoot doctors will naturally strengthen their moral restraint."

  In the 1960s, malaria was endemic in rural areas, but the villagers generally lacked common sense of epidemic prevention.

Ma Wenfang can only send medicines from house to house for consultations to promote anti-malarial knowledge.

If people are not at home, go to the ground to find them.

There are more than 360 households in the village, running once a day for 7 days in a row.

At that time, some villagers felt that they were in good health and did not want to take medicine. The barefoot doctors had to "deliver the medicine to the hand and take it to the mouth without swallowing it."

After completing a course of medication, with a period of time, the medication was delivered from house to house again, lasting for two years, until the malaria was eliminated.

  During the nationwide patriotic health campaign, barefoot doctors, as the most basic executor of the health security system, also assumed the task of "two managements and five reforms".

Barefoot doctors need to manage water and feces, change wells, toilets, livestock pens, stoves, and the environment, and check whether they have been disinfected and disinfected house by house.

As long as the work related to medical treatment, sanitation, and health care, barefoot doctors have to do everything they can do every day.

  The article "Barefoot Doctors and Medical Pyramid" published in the British Medical Journal in 1974 pointed out that as the bottom of the medical pyramid system, barefoot doctors are half farmers and half doctors, which determines that they can only provide basic and simple medical services. , To convey hygiene concepts such as "washing hands before meals" to the public.

They have played a very important role in disease prevention, such as early diagnosis of esophageal cancer in Northeast China and high-risk areas of nasopharyngeal cancer in Guangdong.

  "As a product of a specific historical period, the barefoot doctors and the cooperative medical system are a creation of Chinese farmers when health resources are scarce and the distribution is severely unfair." Associate Professor Li Decheng of Jiangxi Normal University once wrote and concluded that barefoot doctors built a three-level rural area At the bottom of the medical prevention and health care network, measures such as vaccination, vaccinations, and distribution of anti-epidemic drugs implemented by the higher-level health administrative departments can be implemented.

After the "Barefoot Doctor" disappeared

  After 1976, with the end of the political movement, the number of primary health workers, including barefoot doctors, declined at an average annual rate of 400,000.

  At that time, the health department began to regulate the practitioners, control the number and quality of barefoot doctors, and eliminated a batch of unqualified health workers through examination and certification.

The assessment began in 1979.

In 1981, the State Council approved and forwarded the Ministry of Health’s “Report on the Reasonable Solution to the Problem of Barefoot Doctors’ Subsidies”. The document mentioned that “All barefoot doctors who have passed the examination and are equivalent to the technical secondary school level will be issued a'barefoot doctor' certificate. For barefoot doctors who are temporarily unable to reach the level of technical secondary school, the training should be strengthened. In addition to recording work points, appropriate subsidies should also be given according to the actual local conditions."

  After the disintegration of the People’s Commune, with the collapse of the collective economic foundation, the rural cooperative medical system and the barefoot doctor system further lost their organizational support and economic support.

By 1983, the number of barefoot doctors nationwide had fallen to more than 1.2 million.

  On January 24, 1985, Chen Minzhang, the former Minister of Health of the People’s Republic of China, stated in a speech at a meeting of directors of the National Health Department that “the name'Barefoot Doctor' was proposed by Zhang Chunqiao and others in an article at the beginning of the'Cultural Revolution'. Afterwards, it was widely used everywhere. The meaning of this name is not exact. Now we have decided not to use this name. In the future, all those who have passed the examination and have reached the level of doctors are called rural doctors; those who do not reach the level of doctors, They are all renamed as health workers."

  The next day, the "People's Daily" published an article "No longer using the name "barefoot doctors", to consolidate and develop the team of rural doctors", and the era of "barefoot doctors" came to an end.

Barefoot doctors retired, retired, changed careers, and some left the public system and opened clinics at home. Others contracted out the commune’s health clinics, responsible for their own profits and losses, and continued to practice medicine under the name of “barefoot doctors”.

  After the transformation, the barefoot doctors have improved their professional standards through retraining, further education and self-study.

Coupled with the villagers’ original trust in barefoot doctors, village doctors were still very popular in the 1990s. At that time, Ma Wenfang had seen more than 150 patients in a day.

From "recording work points" to "self-financing", the village clinic still has some income. Ma Wenfang keeps enough income for his family to eat and drink, and the rest is fed back to the villagers for medicine and injections, and children who cannot get the vaccine are vaccinated free of charge.

In Ma Wenfang's impression, in the late 1980s and early 1990s, rural doctors briefly experienced a "golden period".

  Soon, by the mid-1990s, the eastern region developed rapidly, attracting a large number of farmers to work outside.

Village clinics are in stark contrast with the large hospitals due to poor hardware, insufficient manpower, and old doctors. As people’s income increases, villagers have gradually formed the consciousness of "going to large hospitals when they get sick."

The survival of the village doctor began to become difficult.

  In fact, the transformation dilemma of the rural primary medical system emerged after the collapse of the "barefoot doctor" system.

Although the main composition of rural grassroots health workers was still the former "barefoot doctors", they lost the original system guarantees and economic support, making a living in a market economy environment driven by interests, and apparently they could no longer afford the "barefoot doctors." The functions of "doctors" such as epidemic prevention and supervision, rural grassroots health networks have been unable to operate effectively since the 1980s.

  "The collapse of the cooperative medical system and the transformation of the role of the'barefoot doctor' have led to a predicament in rural primary health care, and farmers have lost their basic medical insurance." Zhang Daqing said that in 2003, the Chinese government proposed the establishment of a new rural cooperative medical system. Planning and promulgated the "Regulations on the Management of the Practice of Rural Doctors" to rebuild the rural primary health care service system.

However, there are still many inconsistencies between the new rural cooperative medical system and the medical services of rural doctors, and the service system that adapts to the medical consumption level and level of the new rural cooperative medical system has yet to be improved.

  "The current rural primary medical care problem cannot be solved by simply restoring the original barefoot doctor system." Zhang Daqing pointed out that with the development of social economy, people's demand for health care quality is also rapidly increasing, and their awareness of health The financial investment in knowing and maintaining health has increased. There is nothing wrong with the pursuit of better medical services. The state can only guide hierarchical diagnosis and treatment from the design of the system.

More importantly, the system design of the rural primary health service system must clarify its functions and responsibilities.

  After being elected as a representative to the National People's Congress in 2008, Ma Wenfang began to investigate the practice of rural basic medical care and village doctors.

He visited more than 300 villages in 38 prefecture-level cities in 7 provinces, including Henan, Shandong and Hunan, and found that hollow villages are becoming more and more common, village doctors are paid low, and some villages do not even have village doctors, and the level of basic health services in rural areas is worrying.

"Grass-roots work needs specific people to do it. The village doctor subsidizes more than 1,000 yuan a month. In this era, who wants to do it and who will take over in the future? What about the basic medical and public health in rural areas?" Ma Wenfang said worriedly.

  China News Weekly, Issue 41, 2021

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