Mao's Barefoot Doctors: The Secret History of Chinese Medicine

by Brian Dunning
May 24, 2011

Today we're going to take a look at how Chinese alternative medicine spread into the Western world. Promoters of alternative medicine claim that this ancient wisdom was (and is) in common use throughout China, and the Western world is becoming aware of its value. Skeptics of this position point out that alternative medicine was only used in Chinese rural areas where conventional treatments were not available, and it became popular because it was inexpensive, not because it was effective. The actual history brings some interesting perspective onto both of these points of view.

So let's go back and visit revolutionary China, around the middle of the 20th century. Mao Zedong's Great Leap Forward was in full swing, precedent to the Cultural Revolution. At the beginning of this period, most Chinese were one of the world's isolated populations, to whose doorsteps modern innovations had not yet arrived, much like many Africans, Indians, and Indonesians. They lived largely unaware of what was happening in science and technology, and their worldviews were dominated by local traditions. Medicine was rarely seen by any of these populations; when someone was ill, traditional treatments based on centuries of unscientific beliefs were what was known and applied.

Meanwhile, throughout most industrialized population centers in the world, including China's big cities, hospitals practiced the leading edge of medicine. Chinese oncologists prescribed chemotherapy for cancer just like in other parts of the world. Patients in great pain would be given opiates. As early as 1949, the Chinese Academy of Sciences was one of the world's leading research institutions in life sciences and medicine. One difference that you would have seen between Chinese hospitals and those in other nations was the use of acupuncture, which was and still is in relatively wide usage; however, with an important proviso. In China, acupuncture is only used for pain relief, never as a treatment, and always in conjunction with conventional painkiller medications whenever available. It's essentially an ornament alongside the same basic treatments used in other modern hospitals.

This application of the best medical science available was all well and good for those Chinese living in the cities, but it wasn't doing much for those a thousand kilometers out in the country who were scarcely even aware that the cities existed. In 1958, Mao Zedong launched a Communist party magazine in China called Red Flag. Its title on the front page was written in Mao's own calligraphy. Red Flag was the government's primary mouthpiece throughout China for Mao's reform programs, explaining the plans and laying out the philosophy. One of the national problems that Red Flag addressed was healthcare. By 1964, the urban population was still less than 2% that of the national population, with the overwhelming majority living in remote rural areas. Yet that 2% living in the cities received almost all of China's healthcare budget, and all of the benefit of innovations from modern medicine.

Mao's government had tried since 1949 to recruit and encourage doctors to move from the cities to the country, but this had been largely a failure. What healthcare there was had been mainly provided by traveling teams of doctors who would spend a few weeks in the outlying provinces, but would then return to their hospitals in the cities where they could receive a decent income. The problem grew more pronounced with the increasing spread of schistosomiasis, a parasitic disease that caused infection and organ damage, and is most notably characterized by swelling in the abdomen. Schistosomiasis came to be something of an iconic symbol for the lack of healthcare in China.

Mao planned a fix. In 1968, Red Flag published what was to be China's solution. Mao's experience had taught him that efforts to push healthcare out to the countryside were doomed, and so he did the opposite. Farmers were recruited from all over China, given free training, and sent back to their own villages to serve as medical professionals.

Within just a few years, some 150,000 doctors and 350,000 paramedics — half a million workers to serve over half a billion patients — were at work throughout the country. They became known as the barefoot doctors. Candidates were required to be high school graduates. Most received three to six months of training at the nearest hospital, and when they worked as doctors in their villages they accumulated work points just as they did for their normal farming work. (Work points were a system used in communist China to tabulate each family's productivity, for which they could receive grain beyond the basic allotment, or other goods and services.) Barefoot doctors worked no more than half-time as medics; they were still required to continue their agricultural work to prevent productivity from suffering. Many barefoot doctors went on to later attend medical school and became licensed doctors. In fact, Professor Chen Zhu, China's Minister of Health and a Vice President of the Chinese Academy of Sciences, actually began his career as a barefoot doctor in the countryside in Jiangxi Province before deciding to go to medical school.

By 1970, China boasted a great army of half a million paramedics. They were trained and they were stationed throughout the country where they were most needed. But there was still a problem, a very large problem. There were almost no resources to equip the barefoot doctors with medical instruments, supplies, or drugs. There was a medical treatment available for schistosomiasis, but there was no money for the barefoot doctors to provide it. So they employed the one resource China had always had plenty of: Manpower. Schistosomiasis is caused by worms, and these worms are spread by infected snails through a local water supply. Throughout China, barefoot doctors directed workers to clear ponds and streams, and eradicate the snail population. It was quite successful; within fifteen years, this simple technique reduced the incidence of schistosomiasis from ten million per year to just over two million, and in some areas, it was nearly completely eliminated.

Another significant part of their training was in first aid, to address injuries and other medical emergencies. Pre- and post-natal care was also taught, as well as basic hygiene like washing hands before eating. The barefoot doctors were taught to recognize the symptoms of conditions requiring medical treatment, and were trained to refer such patients to the nearest hospital. But what about everything in between; illness not serious enough to warrant hospitalization, wellness care, and simple treatable conditions? Barefoot doctors were enabled to prescribe medications, but the problem was that medication was hard to come by and often too expensive for peasants. Mao knew he didn't have the funds to stock 150,000 new pharmacies throughout China. So, he provided an alternative.

The Revolutionary Health Committee of Hunan Province published a textbook, A Barefoot Doctor's Manual, intended to equip the unequipped barefoot doctor with everything he needed. The manual is amazingly comprehensive, giving instructions for how nearly any expected illness can and should be treated. It covers basic anatomy, birth control, hygiene, and diagnosis. Interestingly, it also anticipates the likely unavailabilty of needed medical therapies. So as a supplement, the bulk of its content is about medicinal herbs: What they look like, how to collect and prepare them, and what conditions they are believed to treat.

When A Barefoot Doctor's Manual reached Western cultures, Chinese alternative medicine went from being a vague curiosity to being an all-out pop-culture fad.

But the book provided a somewhat flawed introduction. It did not provide an insight into what was happening in Chinese hospitals, nor even what most fully licensed medical doctors would have practiced. A Barefoot Doctor's Manual instead showed what the worst equipped Chinese medics would have to resort to under the worst circumstances. Westerners got a slanted perception of Chinese medicine from the book.

While it's true that A Barefoot Doctor's Manual advocates alternative therapies, it also recommends conventional medical treatment whenever available. For example, the manual describes the treatment for Japanese encephalitis. It recommends the use of acupuncture, mud packs, a compress using extracts of toad, and herbal teas. But it also gives the list of conventional drugs that should be given intravenously. Throughout the manual, almost every disease listed includes the conventional medical treatment that should be given whenever available, and the traditional treatment to be given otherwise.

However, I found out something quite interesting when I tried to verify this. There are a number of English translations of A Barefoot Doctor's Manual available. I was intrigued when I saw that the page counts varied widely. Some are as short as 372 pages, some as long as 960. I could only find one edition available in electronic form to allow searching and comparison, and it's the one that's been most widely published in the US. It's from The Running Press, and its full title is A Barefoot Doctor's Manual: A Concise Edition of the Classic Work of Eastern Herbal Medicine. Note that word "concise". Beginning in 1977, The Running Press used to publish a longer version of the book, which is now out of print. Its title was A Barefoot Doctor's Manual: The American Translation of the Official Chinese Paramedical Manual. By scanning through brief snippets of the original full-length text available on Google Books, I found that the complete conventional medical treatment for Japanese encephalitis was given. But searching through the "concise" edition, which I bought, all such mentions of conventional medicine have been deleted. Some 600 pages of sound medical information were cut from the book for Western audiences. What remains is essentially a list of Chinese traditional treatments, with nothing to inform the reader that the barefoot doctors ever relied on anything else. The edition was not simply made concise; it was carefully edited to give a skewed (and untrue) impression of what Chinese medicine is. The publishers changed it from a responsible paramedical manual into a promotion for alternative medicine under the guise of "ancient Chinese wisdom".

And so, when we look at the history as a whole, we find that alternative medicine did not represent what knowledgeable Chinese doctors would have prescribed, at least not since the dawn of science-based medicine; and so the argument that alternative medicine is valid because the Chinese use it, is false. And we also find that the skeptical claim that Mao promoted alternative medicine through the barefoot doctor plan because it was cheap is not quite true either. The plan was an honest attempt to provide the best available medical care, and it only fell back upon alternative therapies when nothing else was at hand...and unfortunately, this was the case...all too often.

By Brian Dunning
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