BMJ No 7093 Volume 314
Education and debate Saturday 24 May 1997
Health in China
From Mao to market reform
Therese Hesketh, Wei Xing ZhuThis is the first in a series of five articles on changing aspects of health care in China
Summary
After the Liberation by Mao Ze Dong's Communist army in 1949, China experienced massive social and economic change. The dramatic reductions in mortality and morbidity of the next two decades were brought about through improvements in socioeconomic conditions, an emphasis on prevention, and almost universal access to basic health care. The economic mismanagement of the Great Leap Forward brought about a temporary reversal in these positive trends. During the Cultural Revolution there was a sustained attack on the privileged position of the medical profession. Most city doctors were sent to work in the countryside, where they trained over a million barefoot doctors. Deng Xiao Ping's radical economic reforms of the late 1970s replaced the socialist system with a market economy. Although average incomes have increased, the gap between rich and poor has widened.
Problems "of vast importance"
"Chinese problems, even if they affect no one outside China, are
of vast importance since the Chinese constitute a quarter of the human
race.... All the world will be
vitally affected by the development of Chinese affairs
... during the next two centuries." These were
B
The China that Russell visited was a country ruled by warlords,
racked by poverty and disease, and ripe for the birth of the Communist
party. There followed a civil war for the control of China between the
Communists and the Nationalists. In 1949 Mao Ze Dong's army was
victorious, but what the Communists had won was a country devastated by
years of war: poverty, malnutrition, and endemic disease existed on a
huge scale, and the industrial base was in ruins. The infant mortality
rate was estimated to be more than 250/1000.
Mao responded to the daunting task ahead by introducing massive social
and economic change. Millennia of social tradition were swept away with
the birth of the commune. This replaced the family unit, taking care of
employment, food supply, child care, education, and health. Basic
health care and preventive services were provided to everyone as part
of the cooperative medical
system.
This almost universal access to health care is one factor
explaining the reductions in mortality and morbidity seen during the
1950s and '60s. However, more important factors were stability after
decades of war, the improvement in socioeconomic conditions, and the
emphasis placed on prevention.(2) Massive immunisation
campaigns were carried out, brothels were closed, and campaigns against
opium use were run. The Great Patriotic Health Campaigns mobilised the
masses in tasks aimed at improving nutrition, sanitation, and water
quality and attacking certain diseases. The anti-schistosomiasis
campaign included organising teams to lance snails with sharpened
chopsticks. The Four Pests Campaign aimed to eliminate flies,
mosquitoes, rats, and sparrows. Sparrows were targeted because they ate
grain. For days and nights people shouted and banged saucepan lids
until the birds fell dead with exhaustion. But as a result the insects
that would have been eaten by the birds now devoured the grain instead.
Eccentric as much of this sounds, the results were remarkable. A number
of infectious diseases such as schistosomiasis, sexually transmitted
diseases, leprosy, and plague were virtually eradicated, in the short
term at least, though some are now returning.
During the 1950s China was isolated by the Western powers, the
Soviet Union being China's only ally. (It was with the help of Russian
expertise that medical schools and hospitals were established.) Mao
felt increasingly that he needed to prove the strength of the Communist
system by expanding its industrial base.
Peasants were abruptly diverted from agricultural work to other tasks
such as irrigation schemes and the new rural industries. As a result,
in some areas crops were left to rot because it was no one's
responsibility to harvest them. Ludicrous production targets were set,
with disastrous consequences. To meet the grain targets farmers were
urged to overfarm the land, which ruined the soil. To meet steel
production targets, peasants were encouraged to set up backyard steel
furnaces. Cooking pots, redundant in those days of communal eating,
were melted down. The results of all this economic and agricultural
mismanagement were disastrous. Estimates for the number who starved to
death vary between 20 and 50 million. Infant mortality rose to over
300/1000.
Infant mortality rate: 37/1,000
Maternal mortality: 50/100,000
Annual number of births: 22,000,000
Gross national product per capita: $470
Life expectancy: 70 years
Adult literacy rate: 81%
The Cultural Revolution was to bring further disruption. Political
struggles in the senior echelons of the Communist party made Mao
vulnerable and led him to intensify his dictatorial rule. Policy
reversals were abrupt and had to be implemented without question or
adaptation.
Mao launched an onslaught on the privileged position of the medical
establishment. Medical schools and universities closed, as did
specialist departments in hospitals. Many professionals, including
doctors, were persecuted and tortured by the Red Guards, the anarchic
groups of young people, who rampaged through the streets destroying
anything representing the Four Olds: old customs, old ideas, old
culture, and old habits.
It became compulsory for virtually all medical graduates to work in the
countryside, usually for years at a time. Some worked as village
doctors and trained locals to be barefoot doctors, while other simply
worked the land. The more senior doctors were often allocated the most
menial tasks - for example, the most experienced paediatric cardiac
surgeon in China was sent to plant rice for seven years.
But some good came of all this. Over a million barefoot doctors were
trained, and although some doctors are bitter about their treatment,
and the prolonged separation from loved ones, many value the experience
they gained of peasant life. The Chinese were keen that the image
portrayed to the outside world at this time was a positive one:
barefoot doctors, growing medicinal herbs, and providing care to the
community at very low cost.(2) The few examples of
excellence became a model for the world and were cited at the Alma Ata
conference. But this was all an integral part of the communal society
and thus in many ways inappropriate for other developing countries.
When the medical schools reopened in 1972 the training was politicised,
selection of students was related to political attitude, course length
was arbitrary, and there was an emphasis on manual labour and Mao Ze
Dong's thought. It was 1977 before standard five year medical training
started again.
Mao Ze Dong's death in 1976 brought an end to the Cultural
Revolution. The power vacuum was filled by Deng Xiao Ping. He realised
that two decades of economic stagnation meant that reform was essential
to China's future survival and growth. The socialist system was
replaced by a market system which essentially allows more rapid
economic growth at the whim of market forces while accepting less
equality. The communes were dismantled, and families could sell surplus
produce at the newly opened free markets. The result was a doubling of
agricultural output in five years, and the per capita income of the
peasants increased by 10-12% a year.(3)
With the open door policy of 1982 foreign investment accelerated the
process of growth. Economic growth is now running at 10% a
year.(4) Average incomes have increased but the gap between
rich and poor has widened, with high inflation, especially for basic
commodities, eroding purchasing power.
In health care the reforms have brought about crucial changes in the
way that health is financed and organised. Some of the issues raised by
the new market in health care will be discussed in the next
article.
References
1 Sidel R, Sidel V W. The health of China.
Boston, MA: Beacon Press, 1982.
2 Taylor C E, Parker R C, Zheng D L. Public health policies and
strategies in China. In: Holland WW, Knox S, Detels R, eds.
Oxford textbook of public health medicine. Oxford:
Oxford University Press, 1991.
3 Schell O. To get rich is glorious - China in the
1980s. New York: Mentor Pantheon, 1985.
4 Financial summary. Far Eastern Economic Review
1997 January 16:68.
Centre for International Child Health, Health Unlimited,
Correspondence to: Dr
Hesketh.
Public Health education notices in Hangzhou. Health education notices are common in China, but they rarely appear in English Mao Ze Dong
Guidelines for organising health care
Four basic guidelines for the organisation of health care were
announced at the First National Health Congress in 1950:
The Great Leap Forward, 1958-60
Facts about China
Population (1995): 1 210,000,000
The Cultural Revolution, 1966-76
The economic reforms
London WC1
N1EH
Therese Hesketh,
research
fellow
London SE1 9NT
Wei Xing
Zhu,
programme manager, East
Asia
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