Saturday, April 2, 2011

赤脚医生 China's Barefoot Doctors

"Barefoot Doctors of Rural China" by Diane Li

I am part of an experimental, emerging group of healthcare workers/folks interested in being healthcare workers, meeting monthly to develop praxis around disabilities justice, class struggle and healthcare.
Eventually, *with fingers crossed* we can hopefully facilitate an emergence of a network of rank and file, industry- wide healthcare workers collective in Seattle.

We have developed an ongoing database of readings around healthcare here. If folks have any suggestions, or recommendations, please let me know. I have been reading some pieces during my free time, but not in any structured way. Most recently, I have been trying to tackle Ivan Illich's Medical Nemesis. It is a challenging piece to read, exciting in its outright criticism of the capitalist medical bureaucracy yet also somewhat disturbing the strains of anti-modernism. When, or if, I ever finish the piece, I will attempt a review.

Just today, I watched a short documentary by US AID about barefoot doctors in rural China, back in 1975. Barefoot doctors are doctors that are recruited from the rural areas to be trained in preventative and primary care skills. They served as the first line of medical expertise for people in rural China, who then made up 80% of China's population. There are certain interesting features about barefoot doctors from this documentary that I think are useful to think about as we imagine alternatives to the form of healthcare we have available in this country. All my observations are from watching this documentary and so, not super well researched!

First off, the barefoot doctors as described in the film, are nominated from the community. They are nominated in open meetings in rural communities and then approved by the local Health Board, subsequently trained for 3 -6 months, accumulating in 2 year training period broken up into phases. The trainings include knowledge of traditional chinese medicine and western medicine, and more importantly preventative and curative methods for local diseases and illnesses, specific to the communities that the barefoot doctors come from. Those who are interested, or talented, could get further training as full-time physicians in the cities. The barefoot doctor positions were predominantly women, making up more than 50% in some cases, and provided a role for women as healers and skilled labor in their communities.

The idea that doctors and healthcare workers need to be nominated and chosen from the community, I think is a very important concept. It assures their accountability to the communities that they serve. Today our doctors and healthcare providers are so distant, cold, functional and unaccountable. The legal system or the state steps in to try to assure accountability in their own fucked up and pretentious ways. Having doctors from communities who can be nominated out of their positions, I think creates a more effective system of ensuring that doctors serve the health of the people and begins a dialogue about how the structures of health provision and healthcare should be a communal effort, not simply based on individual morals and personality. Today, the Hippocratic Oath doesnt mean anything because doctors are out there just to get money and nothing holds them to that oath, except if you have the money and time to fight a huge, long, drawn out court case around doctor accountability...

Furthermore, barefoot doctors were not separated from their communities. It was seen as a role that was complementary with being a farmer or a housewife. In the film, the narrator talks about how farmers would work 40% of the time in the fields, and then serve their time as barefoot doctors for 60% of the time, and be paid the same wages for both kinds of work. This seems like a way to break down the mental manual labor divisions. In their work, the barefoot doctors were responsible for going around the community, being mobile, to treat and talk to members of the community. They had a somewhat more holistic vision of healthcare that didnt focus simply on medication. It also included teaching classes on sanitation, on the safekeeping of human manure for fertilizers, for replacing human manure with pig manure as safer options, and also conducted sessions where the community would come together to clear up clogged drains which were breeding grounds for dangerous mosquitoes and diseases. In addition, they were responsible for testing the levels of sanitation of well water.

The film also highlighted how the medication that was used in the barefoot doctor clinics were both a combination of indigenous, traditional chinese medicine (TCM), as well as western medicine and patients had the option to decide what kind of treatment they preferred. In the clinic backyards, the doctors would grow plots of herb that they would grind up as medication, and also offer community members payments for bringing in wild herbs which were rare or potent. People would make extra cash this way.

When it came to payment, the community would pool together money -- everyone had a small amount extracted from their "workpoints" or wages, and it would be pooled together to pay the barefoot doctor and the supplies. It was a form of Cooperative Insurance Fund which would be matched by the state. It seemed as if once people contributed to the fund, they would have access to whatever service and treatment they needed.

Having just discussed Critique of the Gotha Program with some of my comrades here, I think it is interesting to think about whether the kind of cooperative that existed was something that defied the law of value and decommodification of healthcare, or whether it also continued to uphold the law of value in more masked forms, under state capitalism.

The film presents the barefoot doctor system as a top down effort by the state capitalist regime, though I am skeptical of that. The way barefoot doctors are described in the film seems to me the way doctors/physicians have been presented in the traditional period drama I have seen before -- they were itinerant, worked also with their hands and not merely with their minds, and were also scientists of sorts. In any case, I wonder if the communications and interactions among barefoot doctors of different provinces and regions were facilitated by the state, or if they recognized themselves as a group of skilled workers who got each others' backs, a class by themselves.

I have been very interested in the state socialist feminism of the Chinese Communist Party and have a lot to say about it, and probably will in another post. On a side note, there is a documentary that I really love, called Out of Phoenix Bridge 回到凤凰桥, that describes the experiences of some rural Chinese women in present-day (well, 1997) Beijing who are there as migrant factory workers. It chronicles some of this history of state socialist feminism that the CCP imposed, and some of its strengths and weaknesses, and its presentation of women as productive capitalist workers who "hold up half the sky" but essentially a betrayal of the interests and liberations of many individual women.

Barefoot doctors in CCP China played a role where women could defeat the feudal forms of patriarchy that existed then, that oppressed and exploited women intensely, and provided a state-recognized role for women to play, where they were doctors and skilled workers. However, at the same time, that went hand in hand with an intense control of women's sexuality under the pretext of nation-building.

The film describes how the barefoot doctors had sole monopoly over access to birth control methods like condoms and pills, which they would only give to married couples. To these married couples they would hold sessions on birth control. In fact, the barefoot doctors would have records of the birth control methods that families in their communities utilized, and would check in on the usage. At some point, health and safety precautions become a pretext for state control over reproductivity and sexuality. They would also hold sessions on sexually transmitted infections (STI) and apparently China during that time did not have cases of gonorrhea and syphillis. I imagine though the darker side of this was the intense persecution of sex workers, whether they be in rural or urban areas. In addition, during the time when the One-Child policy was imposed, women who worked in the fields and factories where barefoot doctors serviced, would have their menstrual cycles be tracked by the doctors and be called in to take their birth control pills as assigned.

That, sounds a little freaky.

I recommend this 50 min long documentary! For good and for bad, it helps me think through what alternatives we need to build for healthcare!


  1. man such parallels. I read Illich's book a while back. I took a lot from it, but he takes his critique to crazy levels and borders on intellectual masturbation. Still it's like the extreme left of that debate which is super useful to understand as a provider. Illich is good in that he has an well developed concept of power, which is something that the marxist analysis is generally deficient of. I just got off work, but we should chat about this book sometime.

    I have the manual of the barefoot doctors translated into English I got in a small town lefty book store. Never read it yet, but there's lots of chinese medicine stuff. I'm suspicious about the whole community election process, but it is a great concept. Have you seen Xiou Xiou the sent down girl? The whole barefoot MDs thing was in the context of the cultural revolution and was embued with power, right out of illich. I'm a critical supporter of it and think it's an important lesson, as is Cuban's neighborhood MDs and health centers. still there's a lot of history of the ruling class in those state capitalist formations using institutions like medicine to reproduce ideology and deepen power relations.

  2. I havent read much Illich or Foucault but it seems like what they are both getting at are pretty complementary, about biopolitics, power, control...Yeah when I am done getting through Illich's Greek I would love to talk about it. Any notes from the book you have that you can share? I would love to have some kind of guide to get thru it!
    Also, can you talk more about the Cuban healthcare stuff? I dont know anything about it.
    Havent seen Xiu xiu, I will tho in the next few weeks! I love watching Chinese movies...
    Have you read Elizabeth Perry's Proletarian Power? That book has guided my framework toward the Cultural Rev. I agree w your nuance take on the barefoot doctors and it seems very probable that the massline, serve the people politics operated with hierarchical state capitalist social relations.

    Anyways, thanks for the comment. I am glad it worked!!!