Medical Transitions in Twentieth-Century China

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This volume examines important aspects of China's century-long search to provide appropriate and effective health care for its people. Four subjects-disease and healing, encounters and accommodations, institutions and professions, and people's health-organize discussions across case studies of schistosomiasis, tuberculosis, mental health, and tobacco and health. Among the book's significant conclusions are the importance of barefoot doctors in disseminating western medicine, the improvements in medical health and services during the long Sino-Japanese war, and the important role of the Chinese consumer. Intended for an audience of health practitioners, historians, and others interested in the history of medicine and health in China, the book is one of three commissioned by the China Medical Board to mark its centennial in 2014.

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1 China’s Exceptional Health Transitions: Overcoming the Four Horsemen of the Apocalypse

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Many of the world’s countries experienced major health transitions over the course of the twentieth century. China is no exception, but its passage has been distinctive in many ways. China’s achievement in life expectancy has been truly spectacular, with average longevity more than doubling over the course of the century. Perhaps unique to China, however, have been major health catastrophes, human calamities that call forth the death theme of “the four horsemen of the apocalypse.” In overcoming these dramatic setbacks, China’s health transitions have been marked by distinctive phases, where health conditions have been shaped by its health care systems as well as powerful social determinants of health. These phases have exhibited both distinctiveness among countries and continuity across time.

This chapter reviews the unique and exceptional transitions of health in China over the course of the twentieth century. It should be noted that this paper’s term “health transition” has different connotations than the title of this volume’s reference to “medical transitions.” Medical transitions imply changes in the field of medicine—science, perceptions, practice, and institutions. Health transition is a broader concept dealing with the health of populations, not individuals.

 

2 Changing Patterns of Diseases and Longevity: The Evolution of Health in Twentieth-Century Beijing

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WHILE BEIJING, THE capital of China, cannot be said to be typical of the country as a whole, the relatively ample documentation of the health of its citizens will be used in this chapter to provide a window into the process of health modernization in China over the twentieth century.

The process of health modernization in Beijing began during the late Qing reforms, or “New Policies” era (1901–1911). In 1905 the Board of Police, set up under the new Ministry of Police, had three departments, one of which was the Department of Health Services (weisheng shu). The department was divided into four sections:

1. Street Cleaning: cleaning streets, public toilets, garbage disposal, and controlling sewage and litter.

2. Disease Prevention: preventing epidemics by vaccination and surveillance of hospitals, slaughterhouses, and food shops.

3. Medicine: administering medical schools and hospitals, certifying doctors, publishing medical books, and keeping statistics of births and deaths.

 

3 Maternal and Child Health in Nineteenth- to Twenty-First-Century China

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The welfare of childbearing women and children has been a prominent concern in Chinese culture from ancient times to the present. Historically, maternal and child health was a family-directed, household-centered issue. Beginning in the late nineteenth century, however, China’s pursuit of modernization significantly changed the context and content of medical practice. For late imperial reformers, as well as the Nationalist and Communist regimes that followed the dynasty’s fall, maternal and child health became a crucial component of state building, modernization, and economic growth. While demographic data is spotty or nonexistent for the earlier part of this period, modern statistics show that individual and state initiatives have effected dramatic drops in maternal and child mortality over the past few decades. But as China today seeks to attain a standard of health care consistent with its level of economic development, it must also negotiate systemic health problems engendered by the very policies that have driven its breathtaking economic growth.

 

4 Tobacco Smoking and Health in Twentieth-Century China

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TOBACCO SMOKING HAS been pervasive in China for more than three hundred years. Introduced into East Asia from the Americas by the Spanish and Portuguese in the sixteenth century, tobacco quickly became a commercial crop grown along the South China seaboard. By the 1680s, when the conquering Qing dynasty finally consolidated its hold over China, tobacco cultivation was underway throughout much of the empire. For most of the Qing period (1644–1911), tobacco in the form of snuff or pipe tobacco was widely used in China by both men and women of all ages and social classes.

We now know what some Chinese physicians perceived as early as the seventeenth century: tobacco in any form is hazardous to health. The human cost of tobacco smoking and snuffing in late imperial China must have been great even if, in the absence of quantitative data, we cannot know tobacco’s exact impact on Chinese morbidity or mortality before 1900 or even before 1950 or so. In the late nineteenth century, however, a particularly deadly form of tobacco—the manufactured cigarette—began to be sold in China. Machine-rolled cigarettes, filled with easily inhalable “bright” tobacco, were immediately popular in China just as they were elsewhere around the world. The Chinese cigarette market expanded spectacularly, with sales rising from about three hundred million sticks sold in 1900 to over eighty billion in 1937 (Cox 2000, 17). Still, China was a relatively poor country at the time and many smokers preferred locally produced pipe tobacco to more expensive cigarettes. As a result the per capita consumption of cigarettes in China remained relatively low before 1949, thereby muting somewhat the adverse health effects of cigarette smoke for many in the population, especially those who lived in the countryside.

 

5 Epidemics and Public Health in Twentieth-Century China: Plague, Smallpox, and AIDS

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WHILE EPIDEMICS HAVE occurred throughout Chinese history, the contemporary understanding of public health is a recent import from the West, and these two topics are not necessarily related. But due to the fact that public health and the prevention of epidemics are so closely linked in our modern understanding, it has become common to discuss the two subjects as one in contemporary academic research. Chinese public health came into existence during the intensely rapid changes of the twentieth century, which was also a time rife with epidemics.

This chapter will focus on the relationships between epidemics and the evolution of public health in China, with particular attention to the plague, smallpox, and HIV epidemics. It asserts that the public health and hygienic movements often served the political purposes of the state rather than necessarily addressing the most critical medical problems.

Examined merely on the basis of extant historical records, the frequency of China’s epidemics has seen a constant increase (Zhang 2008, 32–33). Based on statistics from available historical records through the year 1949, the Republican era (1912–1949) experienced the greatest frequency of epidemic outbreaks (Li 2004, 1). Our own statistical analysis of the modern period (1573–1949) also shows that the frequency of epidemics in the Republican era was much greater than in previous times, with 3.08 occurrences per year, while that number was only 1.09 for previous eras (Yu et al. 2004, 24–25). After 1949, owing to the increasing details and completeness of relevant medical records and statistics, there are no years without any reported epidemics. The emergence of this phenomenon in the modern period is certainly related to the fact that the occurrence and spread of disease was facilitated by such aspects of modernity as rapid increases in population, social mobility, and ever-increasing internationalization (Yu 2003, 340–344). More importantly, however, I fear that this apparent trend may also reflect the degree to which there now exists an interest in recording, maintaining, and preserving the most complete possible data. It is only from the twentieth century onward, after the creation of the Public Health Administration, that the practice of recording public health and mortality statistics became one of its key programs. Since then, statistics regarding epidemic diseases have obviously seen a steady increase in both quantity and detail, to the point where it has become impossible to separate the gradual increase in records on epidemics from the increasingly detailed statistics on health and life produced by public health administrations and research departments (Liu 1996 [1937], 441–446).1 In the twentieth century, epidemic diseases—and acute infectious diseases in particular—have been an important factor in threatening the lives of the Chinese people and in influencing both the Chinese psyche and the social order. Both the epidemics themselves and the fact that their danger was ceaselessly recorded and emphasized also hastened and promoted the establishment of public health measures.

 

6 Schistosomiasis

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Farewell to the God of Plague

Mao Zedong

While reading the June 30th edition of the People’s Daily, I found that Yujiang County has rid itself of schistosoma. With my mind racing, I could not sleep. A light breeze brought its warmth, as the rising sun approached my window. Looking at the southern sky in the distance, I happily set my pen to paper.

I.

II.

Crystal-clear water

And emerald hills

Are many,

But of what use?

So many poplars and willows

Dangle in the spring wind.

The people of China

Number six hundred million,

Even Hua Tuo, the legend,

Was helpless

Before this little bug.

Each one as great as Shun or Yao.

Under our command,

Red rain flows like waves,

In thousands of villages

Bursting with weeds,

Men are dying.

Whirling in the wind.

With great effort, we can turn

Green mountains

Tens of thousands of homes

 

7 Tuberculosis Control in Shanghai: Bringing Health to the Masses, 1928–Present

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TUBERCULOSIS (TB) WAS one of the most widespread and deadly diseases in China in the early part of the twentieth century. The Chinese people had a saying about turning pale at mention of the disease, which they believed killed nine out of ten of its victims. This may have been an exaggeration; however, in the first half of the twentieth century, China’s TB mortality rates were much higher than those in Europe, North America, and other Asian nations. Throughout the century, scientific discovery advanced TB control efforts worldwide, but given China’s massive population, developing a system to bring scientific advances to the wide population presented a special challenge. In Shanghai, the speed of the city’s urbanization, and the resulting size and heterogeneity of the population, amplified these challenges.

This chapter examines eighty-five years of efforts to control TB by connecting the population to the health and public health system in China’s largest city. The chapter is based upon archival documents and interviews with providers and recipients of health care. The archival documents include clinic reports and numerous documents from government archives such as the Shanghai Municipal Archives (SMA). Interviewees included thirty-five providers of health care, including six retired doctors who attended medical school in the 1950s, and fifty-three recipients of health care, including forty-five TB patients at a municipal-level facility. Health care providers were identified through snowball sampling and care recipients were identified through respondent-driven sampling.

 

8 The Development of Psychiatric Services in China: Christianity, Communism, and Community

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THE STORY OF the introduction and growth of psychiatric services in China is by no means a linear progression toward the achievement of practices based on science. The narrative is one in which culture, foreign intrusion, economics, familism, and politics (especially politics) all form part of the framework within which the goal of providing accessible, affordable, and effective psychiatric care for all of China’s citizens who require it is pursued. As we shall see, it is a goal that has not yet been achieved, although the efforts to do so continue. The chapter’s content that covers the development of formal institutional care for psychiatric patients from 1898 is built around material from medical missionary sources prior to 1949. For the later periods the discussion is structured using formal policy documents (where available) and published analysis and research, supplemented by the author’s own experiences and observations in China over three decades. We start, however, with a consideration of the question at the core of understanding the development and structure of psychiatric care—epidemiology.

 

9 Foreign Models of Medicine in Twentieth-Century China

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Competing Models during the Republican Era:
Japan, Europe, and the United States

The people of my humble country do not know how to pay attention to health care (weisheng). In particular, they do not know that a country’s strength and prosperity are held up entirely by a strong and vigorous citizenry and that they must therefore pay attention to healthcare. We rely completely on the enthusiastic guidance from all of you assembled here to allow researchers in healthcare to develop and advance from one day to the next. Moreover, the destitute men, women and children in China depend on your church for protection and nurturance, as well as on the instruction in culture and knowledge. This is the great benefit provided by your church to my country. . . . In particular, we hope that you will continue, upon your return to your home country, to advise and protect the people of my humble country as before, in order to transform everybody into strong, healthy and cultured citizens in the future.

 

10 John B. Grant: Public Health and State Medicine

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JOHN B. GRANT (1890–1962) was the “spirit of public health” for modern China, said Franklin Ho (1895–1975) when he was interviewed by Mary Bullock on July 22, 1970 (Bullock 1980, 134n2). Ho, former director of the Nankai Institute of Economics, shared with Grant an interest in analyzing statistics and economics of public health.1 Ho’s view was further supported by those who worked with Grant at the Peking Union Medical College (PUMC). Marion Yang (1891–1983) recalled in her memoirs that Grant would talk to anybody and everybody about public health when few paid attention to it during his early days in China (Yan 1990, 143–153). For almost twenty years (1921–1939), Grant worked tirelessly with his Chinese colleagues in training a cadre of public health professionals and in creating a modern public health administrative system under the Nationalist government. His enormous work had a profound impact on China’s modern health system. Recent publications on Grant indicate that his ideas on public health have valuable relevance to the current debate on the efficient delivery of health care (Litsios 2011; Bu 2012a).

 

11 The Influence of War on China’s Modern Health Systems

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WHEN THE NATIONALIST government established China’s first Ministry of Health in 1928, high rates of infectious disease, maternal and child mortality, and malnutrition still plagued the Chinese people, particularly in rural areas. The political and scientific reforms that swept Japan into the modern era had barely begun to take root even in China’s larger cities, and the high rates of sickness and death alarmed reformers who longed to improve people’s lives and raise China’s standing in the international medical and political communities. Achieving this aim required the adoption of scientific biomedicine and its application to the needs of 350 million people living in considerable poverty in the countryside. Drawing on reforms initiated in Eastern Europe and the Soviet Union after World War I, reformers and statesmen came up with a low-cost strategy of improving health through public preventive care.

This chapter discusses how the Nationalist government pursued this strategy and with what results, discussing both the general situation in the country and the specific situation of Chongqing, its capital during the War of Resistance against Japan (1937–1945). In the 1930s and ’40s, public health care on a scientific biomedical model was a novel idea in China. Although the outbreak of war in 1937 disrupted much of what had been accomplished in the 1930s, by then China had developed a small but growing cadre of physicians, nurses, modern midwives, and sanitary engineers capable of working within the Nationalist state’s biomedical agenda to improve living conditions in China. Many of them moved to the unoccupied southwestern and northwestern provinces during the war, as did several important health agencies. These included the National Institute of Health, the National Central Hospital, and the Central Epidemic Prevention Bureau, all of which retained branches in western China after the war (Fu and Deng 1989; ABMAC 1946). The National Guiyang Medical College (now Guiyang Medical University) remained in Guiyang, Guizhou, and new agencies were established during the war, including the Chongqing Bureau of Public Health and the Sichuan Provincial Health Administration. Rather than curtail the development of health administration and state medicine, the war moved it west.

 

12 The Institutionalization of Chinese Medicine

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THE COMMUNIST VICTORY in the Civil War of 1945–1949 and the proclamation of the People’s Republic in October 1949 did not augur well for the future of Chinese medicine as an independent medical tradition. Under the slogan “cooperation of Chinese and Western medicine” (zhongxiyi hezuo), the Communist Party (CCP) in Yan’an had utilized Chinese medicine to gain the support of the rural population and to meet health care needs in settings where Western drugs and technological resources were scarce. Ideologically, however, the party’s leadership was committed to establishing a health care system modeled on the West, particularly Russia, in which there was little room for a medicine considered to be a remnant of feudal society and its irrational superstitions. In Nationalist-controlled areas, meanwhile, the Chinese-medical infrastructure created during the 1920s and ’30s had been all but dismantled (Deng 1999, 176–191). And yet, less than ten years later a large-scale effort was underway to rebuild Chinese medicine as a modern tradition that would make a unique contribution to the health care of China and even the world. On October 11, 1958, Mao Zedong famously declared Chinese medicine to be “a great treasure-house” and demanded that its resources be forcefully developed. Another quarter of a century later, in 1982, the principle of “paying equal attention to Chinese and Western medicine” was enshrined in the PRC Constitution. Ever since, the country has enjoyed the fruits and problems of an officially plural health care system. (For foundational accounts of Chinese medicine in contemporary China, see Cai, Li, and Zhang 1999; Meng 1999; Taylor 2004; Wang and Cai 1999; Zhang 1994; Zhen and Fu 1991.)

 

13 Barefoot Doctors and the Provision of Rural Health Care

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The year 1968 saw the publication of Ralph Croizier’s Traditional Medicine in Modern China: Science, Nationalism, and the Tensions of Cultural Change, which would become one of the most cited books on twentieth-century Chinese medical history. It focused on one “central paradox and main theme”: why twentieth-century intellectuals, committed in so many ways to science and modernity, insisted on upholding China’s ancient “pre-scientific” medical tradition (Croizier 1968, 2). Through the perspective of cultural nationalism, Croizier argued that these intellectuals were influenced by “the interaction of two of the dominant themes in modern Chinese thinking—the drive for national strength through modern science, and the concern that modernization not imply betrayal of national identity” (Croizier 1968, 229). However, 1968 also marked the inauguration of a massive public health initiative in China, which would have far-reaching consequences for the medical development of the world’s most populous country: a rural medical program that was inspired by the principles of revolutionary socialism and promoted nationwide. This new medical program pitted Chinese and Western medicine against one another and, more importantly, eventually determined the future of the two types of medicine in Chinese villages. This social transformation of medicine in Chinese villages has been largely overlooked by scholars of Chinese medical history. The centerpiece of the program was the introduction of “barefoot doctors” (chijiao yisheng) into Chinese villages at the height of the Cultural Revolution (1966–1976).

 

14 A Case Study of Transnational Flows of Chinese Medical Professionals: China Medical Board and Rockefeller Foundation Fellows

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COMPELLING QUESTIONS ABOUT human health have motivated the transnational flow of physicians for millennia. Egypt was seen as the font of medical knowledge by the Greeks, Persians, and Turkic kingdoms from the thirteenth century BCE to the Roman era. Egyptian physicians were dispatched to the ancient courts of Europe and the Middle East while medical writers plumbed ancient Egyptian texts for knowledge of ancient Egyptian pharmaceutical formulas. In the first millennium AD, Arabic physicians first retrieved and then reinterpreted the classical Greek medical traditions of Hippocrates and Galen. In Asia, trade routes between the Middle East, the Indian subcontinent, and China facilitated the flows of medical practitioners and ideas from west to east and east to west. In her book Needles, Herbs, Gods, and Ghosts: China, Healing, and the West to 1848, Linda Barnes (2000) details the multiple Chinese influences on European medicine in the early modern era. During the sixteenth and seventeenth centuries the Jesuits included medicine in the intellectual repertoire they brought to the late Ming and early Qing courts.

 

15 The Development of Modern Nursing in China

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The need for Chinese nursing leaders is great and can be met only through upholding high standards in nursing education.

—Lin (1938, 8)

In the introduction to her thesis submitted to the Department of Public Health at the Massachusetts Institute of Technology in February 1944, Chinese nurse Zhou Meiyu lamented that the China Ministry of War had not yet agreed to her proposal that army nurses be granted regular ranks (MCANYP 1944).1 The following year, in a booklet geared toward garnering Western support to “help China train enough nurses to safeguard the health of her people,” Zhou observed with satisfaction that “the people in military hospitals no longer consider nurses merely as privates or civilian guests. Nurses have won respectable positions among them” (Chow 1945, 16). Tacitly appealing to supporters of the American Bureau for Medical Aid to China for financial aid to develop the Army Nursing School to include postgraduate training of nursing teachers, Zhou noted that although the war was over, of the 6,400 nurses in China, scarcely 300 were qualified for teaching. “Since the army alone has asked for 2300 additional nurses,” she wrote, “the preparation of sufficient teaching staff to handle the job [is] a serious problem” (Chow 1945, 15).

 

16 The Evolution of the Hospital in Twentieth-Century China

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IN 2010 CHINESE hospitals consumed 76 percent of national health spending, whereas in the United States 31 percent was spent on hospitals and in Australia, 33 percent. The first port of call for most Chinese patients is a hospital outpatient department staffed by specialists, while for 80 percent of Americans and Australians it is a general practice physician. The hospital is so dominant an institution in the Chinese health care system that 90 percent of all in- and outpatient services in the country occur in one—a remarkable feat for an introduced institution with no indigenous counterpart.

Like a successfully introduced plant species, the hospital found its niche in nineteenth-century China and was well-established by the turn of the century. As dramatic changes in the political, economic, medical, and social environment have played out over the past hundred years, the institution has proved remarkably adaptable. It has both outperformed and crowded out potential competitors.

 

Conclusions: The History of Medicine in Twentieth-Century China

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AT THE START of this project, we knew we were attempting something unusual in scholarly terms, for at least three reasons. Firstly, we asked historians who were specialized in one half of the twentieth century—either before or after the foundation of the Peoples’ Republic of China in 1949—to consider their topics across the “long” twentieth century. We were interested to see the contours of continuity and change over the longer time frame in order to avoid the teleologies of any one political regime. Secondly, we asked scholars from different scholarly communities to collaborate, so that our synthetic project would make visible the importance of different national and cultural perspectives on the interpretation of medical history. Fortunately, the last few decades of relative open exchange between China and the West means that we were able to call on experts based in China, Hong Kong SAR, Singapore, Taiwan/Republic of China, Britain, Canada, Australia, and the United States. Lastly, we decided not to limit ourselves to the development of “modern” medicine in China, even though that was the original remit of the China Medical Board. The engagement of the state with Chinese medicine was most pronounced during the Maoist era (1949–1976), but the whole history of modern medicine in China has been framed by the contrast and competition with indigenous medicine. We felt that any survey of medicine in twentieth-century China needed to take this encounter into account.

 

Appendix: Timeline

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