Authors overestimate role of barefoot doctors in China

BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7025.250a (Published 27 January 1996) Cite this as: BMJ 1996;312:250
  1. Tony Jewell
  1. Consultant in public health medicine 2 Bury Road, Stapleford, Cambridge CB2 5BP

    EDITOR,—Paul Johnstone and Isobel McConnan are right to draw readers' attention to primary care in developing countries and its relevance for our “primary care led NHS.”1 I wish to make three points.

    In drawing attention to the appreciable reduction in childhood mortality in mainland China the authors overestimate the contribution that the barefoot doctors made in the late 1960s and the ‘70s (including the period of the Cultural Revolution). The considerable health gain made since 1949 can more accurately be attributed to a combination of factors, such as the absence of major national or civil wars, food rationing, the prevention of urban migration, full employment, and increasing equity between social classes and urban and rural areas. Other infrastructural developments also helped—namely, the development of primary education and the more specific public health policies, such as the movements to control four pests in the 1950s and improvements in basic hygiene, clean water, waste disposal, and universal immunisation.2 The barefoot doctor movement was a potent political symbol used to tackle the rural-urban divide as well as challenge professional medical dominance and show the practical integration of traditional and Western medicine. It is difficult to gauge barefoot doctors' particular contribution, but rural health care always remained dependent on the secondary level hospital doctors, who have received three years' training, and the small county hospitals, local cooperative health insurance schemes, and public health “sanitarians.”

    In other studies of developing countries that are achieving good health at low cost the primacy of political will to achieve improvements in health and wellbeing is emphasised, as well as educational opportunities for women.3 The three key findings from experiences in Sri Lanka, Kerala state in India, Costa Rica, and China are an equitable distribution of and access to public health services and health care, a uniformly accessible educational system, and adequate nutrition at all levels of society.

    My final point is to clarify that socialism needs to be compared with capitalism as political and economic systems while the medical model needs to be compared with the social model (not socialism) when the determinants of health or disease are being explained.


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