Barefoot doctors (Chinese: 赤脚医生; pinyin: chìjiǎo yīshēng) are farmers who received minimal basic medical and paramedical training and worked in rural villages in China. Their purpose was to bring health care 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.
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. In his speech, Mao Zedong criticized the urban bias of the medical system of the time, and called for a system with greater focus on the well being of the rural population. China's health policy changed quickly after this speech and in 1968, the barefoot doctors program became integrated into national policy. These programs were called "rural cooperative medical systems" (RCMS) and strove 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 dominated by Western-trained doctors. 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."
The barefoot doctors usually graduated from secondary school and then received about six months of training at a county or community hospital, though training length varied from a few months to one and a half years. Training was focused on epidemic disease prevention, curing simple ailments that were common in the specific area, and were trained to use Western medicines and techniques. An important part of the Cultural Revolution was the movement of sending intellectuals, and in this case doctors, to serve in the countryside (Chinese: 下鄉; pinyin: xìaxiāng). They would live in an area for half a year to a year and continue the education of the barefoot doctors. About a fifth of the barefoot doctors later entered medical school.
Barefoot doctors acted as a primary health-care provider at the grass-roots level. They were given a set of medicines, both Western and Chinese, that they would dispense. Often they grew their own herbs in the backyard. As Mao had called for, they tried to integrate both Western and Chinese medicine, like acupuncture and moxibustion. An important feature was that they were still involved in farm work, often spending as much as 50% of their time on this - this meant that the rural farmers perceived them as peers and respected their advice more. They were integrated into a system where they could refer seriously ill people to township and county hospitals.
Barefoot doctors provided mostly primary health care services, and focused on prevention rather than treatment. They provided immunizations, delivery for pregnant women, and improvement of sanitation. The income of the barefoot doctors was calculated as if it were agricultural work; they were paid roughly half of what a classically trained doctor made. This funding came from collective welfare funds as well as from local farmer contributions (from 0.5% to 2% of their annual incomes). This program was successful in part because the doctors were selected and paid by their own villages. By the 1960s, there were Rural Co-operative Medical Schemes (RCMS) programs in 90% of China's rural villages.
The work of the barefoot doctors effectively reduced health care costs in the People’s Republic of China, and provided primary care treatment to the rural farming population. The World Health Organization regarded RCMS as a “successful example of solving shortages of medical services in rural areas”. Because of barefoot doctors providing primary health care so that basic health care is an affordable cost and give China’s entrance into the United Nations (UN) and WHO. Moreover, this also demonstrates that many diseases in poor countries can be prevented and solved without significant financial resources or technological transformation, but just need adequate political focus in training and supporting rural-based and non-commercial forms of preventive health care and primary care treatments.
End of barefoot doctors in China
Two-thirds of the village doctors currently practicing in rural China began their training as barefoot doctors. This includes Chen Zhu, China’s former Minister of Health, who practiced as a barefoot doctor for five years before going on to receive additional training.
The barefoot doctor system was abolished in 1981 with the end of the commune system of agricultural cooperatives. The new economic policy in China promoted a shift from collectivism to individual production by the family unit. This shift caused a privatization of the medical system, which marginalized barefoot doctors and their focus on preventive medicine and primary healthcare. The barefoot doctors were given the option to take a national exam, if they passed they became village doctors, if not they would be village health aides. Village doctors began charging patients for their services, and because of the new economic incentives, they began to shift their focus to treatment of chronic conditions rather than preventative care. By 1984, village RCMS coverage had dropped from 90% to 4.8%. Without the public-service oriented work of barefoot doctors, "health-care crises of peasants substantially increased after the system broke down in the 1980s."
In 1989 the Chinese government tried to restore a cooperative health care system in the rural provinces by launching a nationwide primary health care program. This effort increased coverage up to 10% by 1993. In 1994 the government established a program to reestablish primary health care coverage for the rural population, but the efforts remain largely unsuccessful due to the market-oriented nature of healthcare.
In 2003 the Chinese government proposed a new cooperative medical system that is operated and funded by the government. This program is run more like an insurance program. It pays 10 Renminbi per year for each person covered by the program, and ensures coverage for serious diseases. This new program relies heavily on lessons learned from the times of the barefoot doctors, but faces many challenges in providing sufficient, cost-effective care for China’s rural populations. Currently, the rural population in China attempts to migrate to urban areas to seek better healthcare, which is becoming increasingly limited due to growing costs.
The system of barefoot doctors was among the most important inspirations for the World Health Organization conference in Alma-Ata, Kazakhstan in 1978 where the Alma Ata Declaration was signed unanimously. This was hailed as a revolutionary breakthrough in international health ideology - it called for local communities participating in deciding health care priorities, called for an emphasis on primary and preventive healthcare, and most importantly sought to link medicine with trade, economics, industry, rural politics and other political and social areas.
The resurgence of interest in preventive medicine, primary healthcare, and holistic approaches to social welfare worldwide is leading to positive revisitations of the legacy of barefoot doctors. Political restrictions against discussion of the Cultural Revolution in China, however, limit the extent of this debate in China itself.
International development with NGOs
In 1977, Jean-Pierre Willem created an international humanitarian apolitical non-governmental organization of doctors called Médecins aux pieds nus in France. Volunteers work in Burundi, Colombia and Southeast Asia with local healers to develop "medical garden" for herbalism and make essential oils for gemmotherapy. In 1999, Jean-Claude Rodet became the first president of Médecins aux pieds nus Canada working with Mark Smith in the United States. This NGO leads ethnobiological missions based on "proximity, prevention and humility".
- Health in China
- Healthcare in China
- Barefoot lawyer
- Medical missions in China
- Heilpraktiker a category of alternative health workers in Germany and Switzerland
- Barber surgeon a historical category of health worker in Eastern Europe
- Nurse practitioner
- Zhang, Daqing; Paul U. Unschuld (2008). "China's barefoot doctor: Past, present, and future". The Lancet. 372 (9653): 1865–1867. doi:10.1016/S0140-6736(08)61355-0. PMID 18930539.
- Carrin, Guy; et al. (1999). "The Reform of the Rural Cooperative Medical System in the People's Republic of China: Interim Experience in 14 Pilot Countries". Social Science & Medicine. 48 (7): 961–967. doi:10.1016/S0277-9536(98)00396-7. PMID 10192562.
- McConnell, John (1993). "Barefoot No More". The Lancet. 341 (8855): 1275. doi:10.1016/0140-6736(93)91175-l.
- Cueto, M. (2004). The Origins of Primary Health Care and Selective Primary Health Care. American Journal of Public Health, 1864-1872.
- Watts, Jonathan (2008). "Chen Zhu: From Barefoot Doctor to China's Minister of Health". The Lancet. 372 (9648): 1455. doi:10.1016/S0140-6736(08)61561-5. PMID 18930519.
- Bernardi, Andrea; Greenwood, Anna (2014-07-03). "Old and new Rural Co-operative Medical Scheme in China: the usefulness of a historical comparative perspective". Asia Pacific Business Review. 20 (3): 356–378. doi:10.1080/13602381.2014.922820. ISSN 1360-2381.
- Gao 2008
- ‹See Tfd›(in French) Jean-Pierre Willem, Mémoires d'un médecin aux pieds nus, édition Albin Michel - 2009, ISBN 978-2-226-18987-5, Paris.
- Fong Tak-ho. (2006, May 19). "Cultural Revolution? What Revolution?" Asia Times Online. Asia Times Online (Holdings). Retrieved at <http://www.atimes.com/atimes/China/HE19Ad01.html> on June 15, 2011.
- Gao, Mobo (2008). The Battle for China's Past: Mao and the Cultural Revolution. London: Pluto Press. ISBN 978-0-7453-2780-8. Retrieved at <https://web.archive.org/web/20121103094507/http://www.strongwindpress.com/pdfs/EBook/The_Battle_for_Chinas_Past.pdf> on September 2, 2012.
- Xiaoping Fang, Barefoot Doctors and Western Medicine in China (Rochester, New York: University of Rochester Press, 2012).
- Traditional medicine in contemporary China: a partial translation of Revised outline of Chinese medicine (1972) with an introductory study on change in present-day and early medicine. Nathan Sivin (Ann Arbor: Center for Chinese Studies, University of Michigan, 1987. ISBN 0-89264-073-1.
- A Barefoot Doctor's Manual: The American Translation of the Official Chinese Paramedical Manual (Philadelphia: Running Press, 1977). ISBN 0-914294-92-X.
- C. C. Chen. Medicine in Rural China: A Personal Account. Berkeley: University of California Press, 1989. xix, 218 p.p. ISBN 0520062981.
- Anelissa Lucas. Chinese Medical Modernization: Comparative Policy Continuities, 1930-1980s. New York: Praeger, 1982. xiii, 188 p.p. ISBN 0030594545.