Dr Xun Zhou, University of Essex
Located at the foothills of the Great Wall in northern China, just south of Mongolia, is Shanxi province. Sun’s village is just outside of Datong city in northern Shanxi, an old coal mining town also famous for the ancient Yungang Buddhist Grottoes. Until the 1950s, there had been no roads into the village. The majority of villagers here had had little or no contact with bio-medicine or systemised Traditional Chinese medicine. In 1958, with the advent of the Great Leap Forward – the Chinese Communist Party (CCP)’s utopian project to transform China into an industrial nation and ultimately the first communist paradise on earth – a railroad was built to link this previously isolated and sleepy village with the socialist motherland. Public health work was utilised by the state as a tool to bring socialist cultural revolution to those ‘backward thinking’ villagers hence to ‘change the prevailing [feudal] customs and practices]. Sun was then in his 20s. Being one of the very few youngsters in the village to have received some form of education, he was recruited to work as a health auxiliary for the railway although he was not given any formal training. Ten years later, at the height of the Great Proletarian Cultural Revolution, Sun was chosen by his village to be the village Barefoot Doctor in order to fulfil the state quota of at least one Barefoot Doctor per village.
The Barefoot Doctor programme was initially a local rural grassroots, part-time health worker training program that had emerged from eastern China as a result of the collapse of the state rural health system resulted from the Great Leap famine (1958-62). During the Great Proletarian Cultural Revolution (1966-1976), it took on a new political life and was rebranded ‘Chairman Mao’s Revolutionary Approach to Health’. As of 1968, it was officially launched as a nationwide campaign.
Throughout of the Long 1970, the Barefoot Doctor programme and the Maoist Anti-Schistosomiasis campaign became the public face of the People’s Republic of China (PRC) in its relationship with the ‘First’ and ‘Third’ Worlds. As Western public health professionals and policymakers sought a way out of the perceived post-war health crisis, the PRC’s Barefoot Doctor programme and the Anti-Schistosomiasis campaign came to be the ‘best show in town’. They were widely cited by international public health experts as evidence of the PRC’s purportedly superior primary healthcare system. This was simultaneously an implied critique of the earlier approaches taken by the British and the American health authorities as well as other international health organizations, which had foregrounded allopathic medicine and denied the participation of the impacted communities in healthcare delivery. The leaders of the World Health Organization (WHO) at the time felt strongly that the Chinese experience in tackling health problems with limited financial, technological, and human resources should be promoted around the world. This would lead to the adoption of the ‘Health for All’ by the Twenty-Ninth World Health Assembly (1976) as its goal to be achieved by the year 2000, and was formally included in the Declaration of Alma Ata (1978).
In a 2002 interview, however, the former Barefoot doctor Sun would challenge the official claim that the Barefoot Doctor programme was universally successful. He recalled:
There was an official policy regarding the [Barefoot Doctors]. When being implemented, many aspects of the policy were ignored. What has been implemented on the ground resembled nothing of what is said in the official documents … To turn our village into a model, … the big brigade sent us lots of medical equipment to make [the village health centre] look good”
The model turned out to be a ‘Potemkin’s village’: for many years, the village health centre remained an empty, dark room with no drugs, staffed by Sun, the Barefoot Doctor who had no basic medical training. In the meantime, villagers continued to seek help from the local vernacular healer when felt sick.
Lifting the veil of official propaganda to explore the lived experience, my new book The People’s Health is the first systematic study of health care and medicine in the PRC during the Mao era. Using rarely seen archival evidences unearthed across eight impacted Chinese provinces and freshly collected oral testimonies of experts, local cadres, and villagers who participated in or were impacted by these campaigns, my book challenges official claims that large-scale health initiatives in Maoist China were successful. Using two internationally acclaimed initiatives, the Maoist Anti-schistosomiasis Campaign and Barefoot Doctor programme as case studies, it illustrates the complex interactions between policymakers, national and local administration and those communities affected on the ground. It also explores the unintended and negative consequences of political planning and social engineering on the environment and the public’s health.
Health care delivery, public health interventions, and the changes in medical practice occasioned by shifts in political needs at the centre and on the periphery have always impacted health care. This impact is sometimes for the better, but often, because of the unintended and secondary effects of other state policies, it is for the worse. The legacy of the ‘Chinese approach’ to improving people’s health is as complex as all of the other tales of improving health care. While many of the indicators of the people’s health, such as the gross statistics of morbidity and mortality, tended to improve over time, the way individuals experienced such changes was often radically different from the official claims. The experience of those engaged in these processes, both the experts from above and the grassroots cadres, the health workers and villagers from below, points to the importance of undertaking careful examination of the contradictory complexities involved in the implementation of large-scale public health initiatives as well as creating a monolithic health system for a vast and varied country.
What is vital in my account is that it shows that official statistics and global pronouncements about health improvement often turned out to be failures at the local level. The simple fact was that health planners at the centre never fully understood how communities at the periphery perceived their own health needs. One further and important lesson that can be extrapolated from my study of the Chinese experience in dealing with the people’s health is that utopian solutions linking health to absolute ideological goals are bound to frustrate and disappoint those most directly affected. The reality of change, if not improvement, in people’s health relies on multiple variables, which often shift from moment to moment in a kaleidoscope of causations and intended as well as unintended consequences. To a great extent, the crisis of health care in the PRC today as seen in the responses to the Covid-19 is, as my book argues, the result of this complex and contradictory history of the Maoist model in improving people’s health.
About the author: Xun Zhou is Reader in Modern History at the University of Essex. She is one of a growing number of historians pioneering the use of oral and archival evidence to shed new light on the history of the People’s Republic of China. She is the author of The Great Famine in China, 1958-1962: A Documentary History (2012) and Forgotten Voices of Mao’s Great Famine, 1958-1961: An Oral History (2014).