Medical Transitions in Twentieth-Century China

By Bridie Andrews and Mary Brown Bullock

“Rich insights into how one country has dealt with perhaps the most central issue for any human society: the health and wellbeing of its citizens.” —The Lancet

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. This is a thought-provoking read for health practitioners, historians, and others interested in the history of medicine and health in China.

• Language: English
• Publisher: Open Road Integrated Media
• Release date: Aug 14, 2014
• ISBN: 9780253014948

Book preview

MEDICAL TRANSITIONS IN

TWENTIETH-CENTURY CHINA

MEDICAL TRANSITIONS

IN TWENTIETH-CENTURY CHINA

Edited by Bridie Andrews

and Mary Brown Bullock

This book is a publication of

Indiana University Press

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© 2014 by The China Medical Board

All rights reserved

No part of this book may be reproduced or utilized in any form or

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and recording, or by any information storage and retrieval

system, without permission in writing from the publisher. The

Association of American University Presses’ Resolution on

Permissions constitutes the only exception to this prohibition.

The paper used in this publication meets the minimum requirements

of the American National Standard for Information Sciences—

Permanence of Paper for Printed Library Materials, ANSI Z39.48-1992.

Manufactured in the United States of America

Library of Congress Cataloging-in-Publication Data

Medical transitions in twentieth-century China / edited

by Bridie Andrews and Mary Brown Bullock.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-0-253-01485-6 (cloth : alk. paper) — ISBN 978-0-253-

01490-0 (pbk. : alk. paper) — ISBN 978-0-253-01494-8 (ebook)

I. Andrews, Bridie, editor. II. Bullock, Mary Brown, editor.

[DNLM: 1. History of Medicine—China. 2. History,

20th Century—China. 3. Public Health—history—China.

4. Public Health—trends—China. WZ 70 JC6]

R601

610.951—dc23

2014 011883

1  2  3  4  5    19  18  17  16  15  14

Contents

Preface

Acknowledgments

Introduction / Mary Brown Bullock and Bridie Andrews

Part I. Health Transitions

1   China’s Exceptional Health Transitions: Overcoming the Four Horsemen of the Apocalypse / Lincoln Chen and Ling Chen

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

3   Maternal and Child Health in Nineteenth- to Twenty-First-Century China / Tina Phillips Johnson and Yi-Li Wu

4   Tobacco Smoking and Health in Twentieth-Century China / Carol Benedict

Part II. Disease Transitions

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

6   Schistosomiasis / Miriam Gross and Kawai Fan

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

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

Part III. Adaptations and Innovations

9   Foreign Models of Medicine in Twentieth-Century China / Xi Gao

10   John B. Grant: Public Health and State Medicine / Liping Bu

11   The Influence of War on China’s Modern Health Systems / Nicole Elizabeth Barnes and John R. Watt

12   The Institutionalization of Chinese Medicine / Volker Scheid and Sean Hsiang-lin Lei

13   Barefoot Doctors and the Provision of Rural Health Care / Xiaoping Fang

Part IV. Professional Transitions

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

15   The Development of Modern Nursing in China / Sonya Grypma and Cheng Zhen

16   The Evolution of the Hospital in Twentieth-Century China / Michelle Renshaw

Conclusions: The History of Medicine in Twentieth-Century China / Bridie Andrews

Appendix: Timeline

Bibliography

List of Contributors

Index

Preface

THIS VOLUME IS one of several projects which celebrate the centenary of the China Medical Board (CMB). Our aim is to provide a broad overview of the history of medicine in China rather than a narrow institutional history of the CMB, but readers may find it helpful to have a summary of the mission and history of the CMB here.

The CMB’s work began in 1914 when it was created by the Rockefeller Foundation to manage philanthropic funding for the Peking Union Medical College (PUMC), the cradle of modern medicine in China. In the first half of the twentieth century, most of the CMB’s resources went toward the construction and development of PUMC, which was the largest investment project in Rockefeller Foundation history. In 1928, the CMB was endowed as an independent American foundation for the continuing support of PUMC. Through war and chaos, PUMC not only endured but flourished. Its faculty and graduates founded many key clinical specialties in China and developed innovations such as a three-tiered rural health system. The CMB continued to work in China after the establishment of the People’s Republic of China in 1949, but two years later, in 1951, the Chinese government nationalized PUMC, ending the decades-long relationship.

Starting in the 1950s, the CMB expanded its capacity-building work into other Asian countries: Japan, Korea, Hong Kong, the Philippines, Thailand, Indonesia, Malaysia, Singapore, and Taiwan. Today, the CMB remains active in mainland Southeast Asia, supporting universities to strengthen education and research in medicine, nursing, and public health.

In 1980, the CMB accepted an invitation to return to China and has since expanded its support of medical education and research to more than a dozen medical universities. From 1980 to 2008, the CMB invested strategically in medical research and education. In medical education, it developed the Global Minimum Essential Requirements (GMER), seeded innovations, and established four centers at Central South University, China Medical University, Sichuan University, and PUMC.

In 2008, the CMB launched a fresh initiative to strengthen scientific excellence in critical capacities among Chinese and Asian institutions in order to promote equitable access to primary and preventive health services. This initiative refocused the CMB’s efforts on advancing the field of health policy and systems sciences (HPSS), building capacity in health professional education, and directing resources to rural health.

Conventions

For consistency, all our authors are listed by given name followed by family name. Chinese names within the chapters have been given in the Chinese style, family name first, using pinyin romanization. For the Republican era (1912–1949), it has been necessary to make some exceptions to this rule. Before the pinyin system was designed in the 1950s, many Chinese published in English using other romanizations (for example, Jin Baoshan, who published as P. Z. King; and Wu Liande, who published as Wu Lien-teh). In these cases, we have attempted to provide all versions (Chinese, modern pinyin, and the author’s preferred romanization) on first usage. When citing publications written in Chinese, we have indexed names according to pinyin. When citing publications written in English, we have used the authors’ preferred rendering of their names and supplied the pinyin versions in parentheses following those names in the Chinese-language section of the bibliography. For institutions and publications during the Republican era, we have rendered Chinese using traditional (unsimplified) characters; for the People’s Republic of China we have used simplified characters.

Acknowledgments

THIS VOLUME HAS been a couple of years in the making, with input and assistance from many quarters, which we are happy to acknowledge here.

Lincoln Chen first conceived of a series of history volumes to mark the 2014 centenary of the China Medical Board, of which he is president, and provided the resources and enthusiasm that have made it possible. We owe the existence of the volume and the wonderful intellectual exchanges it has generated to his vision. Emma Rothschild helped shape the project and brought the leadership and editorial personnel together over some wonderful dinners, and William Summers, Paul Cohen, and Charles Rosenberg provided essential scholarly orientation during the planning phase.

Our papers got their first readings at a conference held at MIT’s Endicott House with the help of Camilla Harris and Betty DaSilva. Logistical and translation assistance was provided by Bentley University graduate students Angie Mengxi Luo, Wei Wang, Lily Guan, and Ying Zheng, and the complexities of U.S. visa and tax requirements were ably handled by Maria Bergmann, James Fuerst, Donna Delulio, and Donna McKnight at Bentley. We were saddened that illness prevented one of our attendees, Professor Hu Cheng of Nanjing University, from continuing with the project but would nonetheless like to express our appreciation for his contribution here.

In Beijing, CMB staff Echo Zong, Mariel Reed, Roman Xu, and Linda Zhou were gracious hosts, as were Peking Union Medical College staff members Yuhong Jiang and Zhang Xia. Susan Gatewood made sure that everyone arrived safely.

During the editing process, we were fortunate to have the translating expertise of Sabine Wilms and the English editing of Michelle Renshaw. The process of romanizing Russian names correctly was made easy with the kind assistance of Leonid Trofimov, historian of Russia at Bentley. The difficult task of creating a uniform style and bibliography was achieved with great skill and good humor by Rebecca Scofield and Mary Augusta Brazelton. At the CMB Cambridge office, Jennifer Ryan’s editorial professionalism and encouragement was essential to the management of our multiple agendas and deadlines. She was ably assisted by Joshua Bocher. CMB staff Shenique Bennett, Sally Paquet, and Sarah Wood provided essential administrative support.

At Indiana University Press, our project editor Michelle Sybert and copyeditor Eric Levy were expert and conscientious guides through the publishing process, providing consistency and attention to detail that are rare and precious in today’s publishing world. Thank you.

MEDICAL TRANSITIONS IN

TWENTIETH-CENTURY CHINA

Introduction

Mary Brown Bullock and Bridie Andrews

THE MODERN HISTORY of medicine and public health in China is dramatic and complex. Transnational forces propelled medical ideas and practice both within and between East and West. Health concerns moved from an intimate, relatively private personal realm to a concern of the state which imposed often draconian regulations but also introduced state responsibility for health care. The efficacy of newly discovered vaccinations, sulfa drugs, and antibiotics contributed to the epidemiologic transition from infectious to chronic diseases as the main threats to health, while simultaneously transforming Chinese perceptions of Western medicine. The technological discoveries that advanced an understanding of disease causation and sometimes cure led, as the century progressed, to costly technological innovations that greatly escalated the costs of medical care. The emerging new medical institutions and professions were challenged by domestic political and economic forces, including several wars and revolutions. Having weathered those challenges today, China’s health care system, like many worldwide, faces challenges of quality, costs, and unequal care across populations.

Nonetheless, China is no longer the sick man of Asia. A hybrid system of modern medicine which includes traditional Chinese medicine and the most advanced Western medicine is well established. Chinese life expectancy rates doubled in the twentieth century, and today approaches those of the most advanced economies. Infectious diseases, often associated with poverty and poor living conditions, have declined dramatically even as some persist, often in virulent forms. Chinese medicine is one of China’s most successful cultural exports and China is a significant provider of health assistance to Africa.

The work collected here is published on the occasion of the centennial of the China Medical Board, which was established by the Rockefeller Foundation in 1914 to create and manage the Peking Union Medical College (PUMC), which in turn quickly became the preeminent medical education and research institution in China. When PUMC was closed in 1951 the China Medical Board extended its work to medical schools in other parts of East and Southeast Asia. Since 1980, the CMB has returned to China, supporting thirteen medical schools and initiating programs in health policy and rural health. Although several of the chapters refer to the activities of the CMB, this volume is not intended as an encomium to Rockefeller medical philanthropy. Indeed, our authors were charged with not paying special attention to the activities of the China Medical Board. As Lincoln Chen—current president of the CMB—and Ling Chen argue in their chapter, the greatest improvements in population health and longevity occurred during the Maoist era, after U.S. agencies were expelled by the Chinese Communist Party in 1952. Nonetheless, our study of a century of medical history in China, focusing on the activities of medical professionals (doctors, nurses, midwives, health advisors) and on disease management, reveals that many of the CMB-trained professionals were key to the construction of the health care system both before and after the establishment of the People’s Republic of China. Indeed there is much evidence in this volume that the medical institutions, research, and health care programs of the Republican period, many of which were funded by the Rockefeller Foundation and the China Medical Board, were key to the later advances made by the People’s Republic of China. As Chinese society has opened up to market economics since the 1980s, and the iron rice bowl of government welfare has disappeared, problems of refractory infectious diseases and unequal access to health care have reemerged. It is striking to note how similar today’s proposed solutions are to those proposed in the 1930s by delegates from the League of Nations Health Organization and the CMB.

The voices of patients are never far from the surface, and they are often critical of the schemes of government. For example, in Daqing Zhang’s chapter we hear of vaccination programs with low acceptance rates. We also observe in Xinzhong Yu’s chapter that because of Communist Party authoritarianism in the past, today’s Chinese citizens are no longer willing to cooperate with government-led mass movements in health. We see this confirmed in Miriam Gross and Kawai Fan’s chapter on schistosomiasis: patients were happy to accept the Praziquantel drug treatments when they became available, but were reluctant to engage in (largely futile) snail eradication efforts. The mistrust the public now has for mass health movements may be what is driving the enthusiasm for U.S.-style health insurance schemes today, with their health savings accounts which, while inadequate for dealing with major individual health crises, do have the virtue of remaining in the control of individual patients.

Western medical missionaries, key to any understanding of how modern medicine was transmitted to China, deserve a volume of their own. They feature here as instigators of many modern health initiatives: they brought a model of health care that was firmly rooted in the specialist institution of the hospital, as we see in Michelle Renshaw’s chapter; and they attempted to medicalize the treatment of the mentally ill, starting with John Kerr’s Refuge for the Insane in late nineteenth-century Canton, described here by Veronica Pearson. Sonya Grypma and Cheng Zhen describe how missionaries set up nursing education programs and Tina Phillips Johnson and Yi-Li Wu describe missionary-run medical schools for women, both of which created new roles for Chinese women in public life. Missionaries translated the first Western medical texts for use by Chinese students, and we should not forget that in rural areas, many farmers’ only experience of Western medicine before 1949 came from mission clinics, as missionaries would go to practice in impoverished areas when the newly qualified Chinese medical elites would not.

The economics of health care feature in several of our chapters, most notably in Xiaoping Fang’s chapter on the barefoot doctor movement, Xi Gao’s account of the reasons China adapted different foreign models of health care, and Volker Scheid and Sean Hsiang-lin Lei’s account of the institutionalization of Chinese medicine. In recent years the rising cost of health care and increasing income disparities between urban and rural areas have recreated a crisis in access to health care in China. The government is attempting to ameliorate these disparities through a series of reforms that health economists, health policy advocates, and scholars of medical history are watching closely. The very great economic as well as technical challenges involved in extending medical provision are demonstrated in almost all of our chapters, perhaps in none more than Veronica Pearson’s overview of the development of mental health services.

No single volume can possibly provide a comprehensive record of these developments. The history of medicine and health has become an important endeavor of scholars worldwide, precisely because it operates at this nexus of governmental power and local and individual agency, with important things to say about culture and ideology as well as access to economic resources. With its long historic records and complex evolution this is especially the case with medicine and health in China. Drawing on scholarship from China, Australia, Taiwan, Germany, Canada, and the United States, this book presents, for the first time, an overview of medical transitions in the twentieth century. Drawing on scholarship from Australia, Canada, China, Hong Kong, Singapore, Taiwan, the United Kingdom, and the United States, this book presents, for the first time, an overview of medical transitions in the twentieth century. Of particular note are chapters by four scholars—Daqing Zhang, Xinzhong Yu, Xi Gao, and Cheng Zhen—who usually write for a Chinese audience. Several chapters notably include the roles of both Chinese medicine and traditional-style doctors. Our study also highlights how new drugs and vaccinations depended on both individual and state-led efforts for their therapeutic successes.

The factors influencing medicine are many, and include social, political, and economic conditions as well as new understandings of hygiene and science. Geographical proximity to medical care, most often differentiated by urban or rural location, is also of the utmost importance. All of these were in flux in twentieth-century China. Likewise, changes in the delivery of health care from the home to the hospital, from laypersons to specialists, brought marked changes to the ways in which illness is treated and health maintained. In this book these medical transitions are discussed in four sections: health transitions, disease transitions, adaptations and innovations, and professional transitions.

Health Transitions

Historians and political scientists have tended to view China’s twentieth century as segmented between the late Qing, the Republican, and the People’s Republic eras. In different ways the chapters in this section demonstrate how transitions in health care occur continuously across the century, sometimes, but not always, marked by political change. Other factors, notably scientific advances in medical therapies and changes in economic and social systems, contribute to dramatic health changes. Beginning with an overview of China’s mortality and demographic changes, we turn to three specific examples of these macro-level changes across the century: the health transitions in the city of Beijing, in the maternal and child health sector, and in tobacco and smoking usage.

Lincoln Chen and Ling Chen’s chapter, China’s Exceptional Health Transitions, sets the theoretical stage for this section, and the statistical stage for the entire book, as it explores the major causes of mortality and demographic change across twentieth-century China. The transitions examined are the epidemiologic, demographic, and health transitions. The epidemiologic transition occurs as populations progress from higher to lower mortality levels associated with rising incomes and improving health systems. Whereas poverty-linked diseases such as childhood infections, malnutrition, and maternity-linked burdens characterize low-income societies, the noncommunicable chronic diseases like cancer and heart disease dominate in higher-income countries. Demographic transition theory captures changes of fertility and mortality from high to low levels. The time gap between an earlier reduction of mortality and the later decline of fertility generates a gap between birth and death rates that accelerates population growth. In addition to rates of growth, demographic change may also affect the spatial distribution, age structure, and other parameters of human populations. These two theories of transition are brought together in the theory of the health transition, which integrates not only epidemiologic and demographic parameters but also changes in sociocultural perceptions, health-seeking behavior, and the structure and operations of health systems. This chapter uses health transition theory as an interdisciplinary framework to outline the multiple dimensions of changes related to the health of the population of twentieth-century China.

From this macro-overview we turn to health transitions in a specific place, the city of Beijing, analyzed by Daqing Zhang. This longitudinal study discusses how the social and political environment in modern China has undergone dramatic changes from periods of continuous warfare to political chaos to peace. From the foundation of the Republic of China in 1912 to the mid-1930s, the new national medical administration system had to be restructured several times in accordance with the changing political environment. Despite these changes, the causes of disease mortality transitioned from infectious diseases to chronic and degenerative conditions.

Another way to examine health transitions is through the status of maternal and child health, a universal indicator of a nation’s health. Certainly the welfare of childbearing women and children has been a prominent concern in Chinese culture from ancient times to the present. Many older, indigenous practices are still relevant in maternal and child care practices today. At the same time, the social context and intellectual content of medicine in China has changed significantly as a result of the Chinese pursuit of modernization beginning in the late nineteenth century. Tina Phillips Johnson and Yi-Li Wu trace this evolution in their chapter on maternal and child health, observing that whereas maternal and child health was a family-directed, household-centered issue during the Qing, under both the Republican and Communist regimes it became a crucial ideological component of state building, modernization, and economic growth. As a result of both individual and state initiatives, the past century has witnessed dramatic drops in maternal and child mortality. Economic reforms since 1978 have also vastly increased the resources potentially available for maternal and child health. But as China attempts to achieve a standard of health care consistent with its level of economic development, it will also have to negotiate systemic problems engendered by the very policies that have driven its breathtaking economic growth. These include particularly the policies that removed state subsidies from hospitals and made them profit centers.

The final chapter in this section is Carol Benedict’s Tobacco Smoking and Health. This chapter traces changing ideas about tobacco and health in China across the twentieth century, beginning with new medical discourses about tobacco that were constructed early in the century in dialogue with the transnational anti-cigarette movement centered in Great Britain and the United States. It explores popular views of tobacco’s harms in the 1930s literature of leisure and advice columns of women’s magazines. The chapter also describes changing patterns of tobacco consumption across the twentieth century that had implications for health and concludes with a brief history of recent tobacco control efforts in the People’s Republic of China.

Disease Transitions

Changes in global disease patterns during the twentieth century were dramatic, in part due to scientific discoveries which brought more effective prevention and treatment as well as economic improvements in many people’s lives. While the diseases discussed in this section have been universally prevalent, they are selected here because their trajectory in China has been distinct. Writing from the discipline of history, the authors illustrate how the convergence of political, cultural, ideological, and scientific forces can dramatically influence the course of diseases. Three of the four chapters focus on infectious diseases because these were responsible for the highest mortality rates for the first two-thirds of the century. Today, noncommunicable diseases (cancer, heart disease, and diabetes) claim more lives and they are well-covered in medical journals and most recently in a series of articles in the Lancet. Mental health, however, is now considered China’s number one medical problem. Here, as in other chapters in this section, Chinese culture and political ideology have dramatically affected the course and treatment of mental health-related diseases.

The first chapter on disease patterns, Xinzhong Yu’s Epidemics and Public Health in Twentieth-Century China: Plague, Smallpox, and AIDS reminds us that the century began and ended with virulent epidemics, even as vaccinations rendered smallpox obsolete. The twentieth century demonstrated what William McNeill termed a homogenization of disease, facilitated by new forms of more rapid transportation, the imposition of Western institutions with their circulation of personnel and their diseases, and the increasingly hegemonic role of biomedicine in identifying and controlling infectious diseases. Yu argues that although public health measures were developed primarily to control disease, they were also undertaken to reinforce the power and legitimacy of the state under the Qing, the Republican, and the People’s Republic of China governments.

Schistosomiasis, a water-borne and snail-transmitted disease, has a storied political history, well illustrating the intersection of politics and medicine in China. Chairman Mao’s historic campaign against schistosomiasis is widely considered by the Chinese government and most Chinese people as one of their most successful and well-run health crusades. It became a symbol of the Communist Party’s care for the people, brought international attention to the Chinese public health model, and still serves as an important model for current campaigns against SARS, avian and swine flu, and AIDS. Since the construction of the Three Gorges Dam, schistosomiasis has garnered increasing notice as a critical public health issue in contemporary China, and the disease has been growing at epidemic rates since 2001. Miriam Gross and Kawai Fan’s chapter on schistosomiasis examines the history of the disease and the Chinese government’s campaign to eradicate it against the political background that made treatment of Chinese troops a strategic priority, and encouraged Mao to encourage the anti-schistosomiasis campaign as a model mass movement.

Rachel Core’s chapter, Tuberculosis Control in Shanghai: Bringing Health to the Masses, 1928–Present, turns to one of the most deadly diseases in early twentieth-century China. Throughout the century biomedical discoveries combined with political and socioeconomic forces to modify TB control efforts worldwide; however, 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 a century of efforts to connect the population to the health and public health system in order to control TB in China’s largest city. The chapter is divided chronologically into three sections, each of which coincides with larger socioeconomic developments. The first section examines limited success in bringing primary and tertiary TB prevention to affected individuals during the period 1914–1949. The second section considers widespread efforts to bring the disease under control after the 1949 Communist Revolution. During the height of the Socialist era, 1958–1978, TB control programs became systematized, with district prevention and treatment stations overseeing efforts within individual workplaces. The relationship between district stations and individual workplaces, which provided an effective link ensuring that scientific advances could reach the masses, continued through the 1980s. In the 1990s, China adopted the World Health Organization’s Directly Observed Therapy, Short-Course (DOTS) TB control program at the same time that the workplace-based urban health insurance system began to collapse. The final section discusses the ongoing challenges of bringing TB control to the masses in an era of wide-scale in-migration.

Today China views mental health as one of its most significant health issues. Veronica Pearson’s chapter reviews the history of attempts to provide humane health care for the mentally ill. She outlines the many obstacles that stand in the way, perhaps most seriously the stigma that is still associated with mental illness. By the 1950s, the study of such bourgeois subjects as sociology and psychology had been banned in Chinese universities, precluding any study of the particular sociocultural aspects of mental health in China. Yet, ironically, the centralized education and job assignment system of the Mao years meant that mental hospitals were assigned medical staff, even if the staff members themselves were often reluctant. Now that students may choose their own specialties and apply for their own jobs, it has become even harder to find and train mental health professionals. The chapter ends on a hopeful note, documenting the government’s new initiatives to reform mental health care both in the community and in institutional settings.

Adaptations and Innovation

The twentieth century was an era of three revolutions (Nationalist, Communist, and Cultural) and four wars (World War I, the Sino-Japanese War, the Civil War, and the Korean War). Across this turbulent period there were significant adaptations and innovations in China’s medical theory, practice, and professions. During the first half of the century foreign spheres of influence included medicine and public health. For much of the second half of the century more indigenous forces adapted foreign models and modified traditional models to shape new China’s medical system. The first chapter in this section views adaptation and innovation from the perspective of foreign medical systems. It differentiates among the German, British, American, and Japanese influences in the first half of the century and also includes a critique of Soviet influence during the first decade of the People’s Republic of China. The second two chapters cover the less well-known but formative evolution of public health during the Republican period. Both chapters argue that well-trained professionals worked with the Nationalist government and regional provincial governments to improve the health conditions of the Chinese people. Although the health statistics from the 1920s to the 1940s reveal little change (see figure 1.1), the dramatic progress in the 1950s was due in no small measure to the institutions, health models, and professional experience gained in these earlier decades. The most significant adaptation of the twentieth century was surely that of traditional Chinese medicine. New perspectives on the institutions and popular practice of traditional medicine are transforming our knowledge of the extraordinary evolution of this classical medical tradition. The last two chapters in this section, one on the institutionalization of Chinese medicine and the other on barefoot doctors as transmitters of both traditional and Western medicine, illustrate these newer findings and interpretations.

Xi Gao’s chapter, Foreign Models of Medicine in Twentieth-Century China, describes how the adaptation of modern medicine in China drew on several national styles, most notably Anglo-American missionary and secular models, German-Japanese-style state medicine, and the socialist model developed in the Soviet Union. This chapter examines each of these influences and discusses the ways in which elements of each were adapted for use in China. Different models have waxed and waned in influence, and the reasons for this and for regional variations in medical styles are explored. Broadly speaking, during the first half of the twentieth century Anglo-American influence was most strongly felt in the south of China, but Chinese distrust of foreign motives and paternalism led Canton to lead the way in establishing independent medical schools and an urban public health infrastructure based on this model. In northern China and especially Manchuria, German-inspired Japanese-style medicine was more frequently studied and emulated. In the Communist-held areas and in the first few years of the PRC, the Soviet influence was most closely followed, while market reforms and the opening to the West have expanded the medical marketplace in recent years. China (like the United States) has still to settle on a satisfactory health care delivery system that can meet national development goals and provide basic medical care while at the same time fostering excellence and innovation in medicine.

John B. Grant (1890–1962) has been praised as the spirit of public health for modern China. Liping Bu’s chapter, John B. Grant: Public Health and State Medicine, focuses on three interrelated aspects of Grant’s work that had longterm implications for China’s public health profession and health care system. First, the development of the Department of Public Health at PUMC to train public health professionals; second, the creation of health stations in rural and urban settings as experiments of pilot projects to study health conditions and deliver health services; and third, Grant’s assisting the Chinese government in establishing a modern national health administration with state medicine. For Grant, the first priority in the establishment of state medicine was to train high-caliber personnel, which he implemented both at PUMC and in the fieldwork settings of his innovative health stations. Second, as Grant wrote, the most important would be the establishment of a centralized medical authority with power to execute the adopted policy on a nation-wide scale (1928, 79). Grant’s promotion of state medicine set in motion an extensive debate in China. Many Chinese medical leaders supported state medicine but they seemed to understand the concept differently. Some focused on health service to all—rich or poor, rural or urban—while others emphasized the importance of a centralized health administration. This chapter explores these debates and their long-term consequences through Grant’s activities in China and the careers of his students.

In their chapter titled The Influence of War on China’s Modern Health Systems, Nicole Barnes and John Watt come to the counterintuitive conclusion that this war, by causing so much human suffering, greatly stimulated the development of public health care in Nationalist China. Public health organizations developed in the war years were stronger in western than in eastern China, dependent on visionary leadership, opposed by conservative leaders particularly in the military, deprived for much of the time of essential resources, and subject to enemy destruction. The chapter’s focus on medical institutions in Chongqing vividly demonstrates the progress that was made under wartime conditions. The medical organizations developed new systems of management in both urban and rural settings, and trained thousands of individuals in hygiene, sanitation, and preventive medicine. This body of trained health care leaders and workers was one of Nationalist China’s lasting contributions to postwar China.

Volker Scheid and Sean Hsiang-lin Lei’s chapter on the institutionalization of Chinese medicine argues that the process that led to the creation of a pluralistic combination of Western and Chinese medicine was neither linear nor the outcome of a well-thought-out master plan. Rather, it was the product of an underdetermined and piecemeal process that owed more to a careful manipulation of Chinese medicine’s value as a cultural legacy than to any consideration of its actual therapeutic value. The emergence of plural health care in contemporary China thus might be said to mirror the tortuous, painful, and frequently contradictory path the country itself has taken into the present. It is important to remember that 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, in particular 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 was all but dismantled. 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. Another quarter of a century later, in 1982, the principle of paying equal attention to Chinese and Western medicine was enshrined in the Constitution. Ever since, the country has enjoyed the fruits and problems of an officially plural health care system.

Xiaoping Fang’s Barefoot Doctors and the Provision of Rural Health Care makes the unexpected claim that barefoot doctors played a pivotal role in introducing Western medicine and displacing Chinese medicine in rural China. The barefoot doctor program was one of a series of landmark events in the long-term historical development of rural health and medicine in China since the early twentieth century, alongside the initiation of the experimental rural health programs in the 1930s, the founding of the Communist regime in 1949, the popularization of the barefoot doctor program in 1968, the disintegration of the barefoot doctor group around 1983, and the recent rural medical reforms. The essence of this developmental trend remained the same: the introduction of Western medicine (i.e., modern medicine) in terms of its institutionalization, the development of new professional roles, and the promotion of science. The barefoot doctor program, which lasted from 1968 to 1983, was a pivotal stage in the displacement of Chinese medicine by Western medicine in rural China. During this process, the state played a significant role by mobilizing private medical practitioners into establishing union clinics, implementing the barefoot doctor program, mandating large reductions in pharmaceutical prices, creating a new hierarchical and coordinated medical system, and redefining medical legitimacy. Within this context, Western medicine was introduced into Chinese villages under socialism within just three decades. The significance of the barefoot doctors lies in their role in the contest between Chinese and Western medicine in the village arena, the evolution of the three-tier medical system, and the formation of a new professional group. Entering the twenty-first century, the state still plays the leading role in the transformation of rural medicine through the recent medical reforms.

Professional Transitions

The relationships between doctors, patients, and the state went through several dramatic changes in the course of the twentieth century. Until the Nanjing decade, there was almost no licensing of physicians: anyone could practice as a doctor. To distinguish themselves from traditional doctors and self-taught or only partially trained practitioners of modern medicine, Chinese doctors with biomedical degrees organized themselves into professional organizations starting in 1915. During the 1930s, these associations merged in order to be able to negotiate with one voice with the Nationalist Government. The profession fought hard to gain and protect its privileges as the only legitimate representative of modern medical practitioners, but it was always in competition with less qualified practitioners who were never effectively banned. In 1949, the Ministry of Health regulated medical practice, including the work of medical doctors (MDs), middle- and lower-level health workers, and Chinese medical practitioners. The modern nursing profession was dramatically downgraded. Although biomedicine was never able to achieve a monopoly on medical practice, the presence of many highly educated doctors in powerful positions in the Ministry of Health provided a buffer between medicine and some of the worst political excesses of the 1950s and 1960s. The prestige of doctors was highest during the 1980s, but decollectivization has required hospitals to become economically self-supporting, leading to a fee-for-service environment in which many patients suspect that they are being charged for unnecessary but expensive tests, drugs, and interventions. In China today, the profession is in a crisis brought on by these fiscal changes and the concomitant loss of patient trust.

The chapters in this section review three aspects of the changing status and role of medical professionals and institutions, which shed light on the medical professional crisis today: the early formation of American-trained medical and public health personnel, the evolution of the nursing profession, and the primacy of hospitals in China’s health care systems. Elite physicians and the Flexnerian educational model, the nursing profession, and the modern hospital are all aspects of the Western medical system that was introduced to China. In each case, however, the particular professional model was either incomplete or limited in its appropriateness for a heavily populated, developing country such as China. Today’s medical reforms are attempting to address these challenges.

Transnational flows of medical personnel were an important aspect of the internationalization of medicine in the twentieth century. For most of the century Chinese medical personnel traveled to and from Japan, Europe, and the United States. Mary Brown Bullock’s A Case Study of Transnational Flows of Chinese Medical Professionals examines this intellectual migration through an analysis of the medical fellowship programs of the China Medical Board and the Rockefeller Foundation, primarily during the period 1914–1951. Utilizing fellowship files for 350 physicians, nurses, and public health specialists it identifies the primary Chinese home institutions and American training institutions as well as sheds light on the subsequent professional careers of those trained abroad. The data reveals that Harvard and Johns Hopkins Universities became critical nodes in this trans-Pacific program, especially for those in the field of public health. It also reveals that China’s Republican-era National Health Administration was a primary beneficiary of the program: nearly one hundred of its key leaders were trained in the United States. The overall significance of this program includes the fact that almost all returned to progressively important positions in China’s health system and that the American Flexnerian model of medical education had an extensive influence in China. After the renewal of diplomatic relations in 1979, the trans-Pacific flow of medical personnel resumed—reuniting many of the same institutions but on a much larger scale.

Sonya Grypma and Cheng Zhen’s chapter on nursing begins with the intersecting nursing careers of Nie Yuchan and Zhou Meiyu, who illustrate the interrelatedness of key people and organizations in the first half of the twentieth century. As students at PUMC and Rockefeller Fellows, both perceived nursing as a way to provide patriotic service to China, were offered leadership roles in PUMC and Nurses Association of China (NAC), and made career decisions in response to wartime needs. Yet they had differing ideas about the best form of education for nurses. Whereas Nie followed the American model of (baccalaureate) nursing education established at PUMC and recreated at the West China Union University, Zhou responded to urgent army needs by creating a modified version of the Ministry of Education nursing curriculum, along with a series of shorter courses for emergency technical personnel (X-ray technician, sanitary engineering, laboratory technician). While PUMC, Rockefeller Fellowships, and the NAC provided the educational and other preparation and advancement opportunities for a small number of highly capable nurses—a Chinese nursing elite—it was wartime that helped shape Chinese nursing from a form of Christian and professional service administered by foreigners, into a patriotic, nationalized service administered by highly qualified Chinese nurses. Under the PRC, nursing training was abolished until the late 1970s, and since then nursing activists have been negotiating to reestablish professional training and expanded fields of activity for Chinese nurses.

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. In her chapter The Evolution of the Hospital in Twentieth-Century China, Michelle Renshaw describes the introduction of the hospital and dispensary as sites for the distribution of medicine and evangelism by Christian missionaries, the establishment of government hospitals as sites of modernization and control in the early twentieth century, the Republican government’s experiments with state medicine centered on hospitals, and the continued centrality of the hospital under CCP rule. Noting that patients still decide for themselves which clinics and specialties to attend, the chapter ends by describing health care reforms that aim to allocate a supervising general practitioner to every patient, following a modern Russian model, while implementing the new universal health care insurance system.

By concluding with the professional and institutional challenges of health care in China today this volume demonstrates that China’s twentieth-century health transitions are continuing. In the early twenty-first century the People’s Republic of China embarked on massive health reforms only briefly touched on in these chapters. The vibrant history of health transitions depicted herein provides a benchmark for understanding the future trajectory of health and medicine in China.

PART I

HEALTH TRANSITIONS

1     China’s Exceptional

Health Transitions

Overcoming the Four Horsemen

of the Apocalypse

Lincoln Chen and Ling Chen

Introduction

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.

By using the term health transition, this chapter brings together several major transition theories. The theory of the epidemiologic transition describes the changing pattern of disease and cause of death as populations progress from higher to lower mortality levels associated with rising incomes and improving health systems (Omran 1971). Whereas poverty-linked diseases such as childhood infections, malnutrition, and maternity-linked burdens characterize low-income societies, noncommunicable chronic diseases like cancer and heart disease dominate in higher-income countries. Demographic transition theory, similarly, captures changes in fertility and mortality from high to low levels (Caldwell 1976; Davis 1963; Frederiksen 1969). The time gap between an earlier reduction in mortality to the later decline in fertility generates a gap between birth and death rates that accelerates population growth. In addition to rates of growth, demographic change may also affect the spatial distribution, age structure, and other parameters of human populations. These two theories of transitions are brought together in the theory of the health transition, which integrates not only epidemiologic and demographic parameters but also changes in sociocultural perceptions, health-seeking behavior, and the structure and operations of health systems (Caldwell 1990; Frenk et al. 1989; Frenk et al. 1994; Mosley and Chen 1984). As such, health transition theory is comprehensive, holistic, and interdisciplinary in describing the multiple dimensions of simultaneous changes related to the health of populations.

Using the framework of health transitions, this paper opens with an assessment of changing health conditions in China over the course of the twentieth century. Though they started with health backwardness in the beginning of the century, China’s current health conditions rival those of more economically advanced countries. Perhaps uniquely in the world, China demonstrates these remarkable health achievements by overcoming unprecedented health catastrophes. The chapter then probes the nature of these health changes by examining patterns in the cause of death, again showing China’s shift from poverty-linked to affluent lifestyle patterns in the burden of disease. Assessment of China’s epidemiologic transition is followed by a review of China’s demographic transition. The chapter concludes by looking to the future through an analysis of the reform of China’s health system, a recurring theme throughout the century.

Two caveats are indicated. First, the data sources for China’s health conditions, causes of death, and population size and distribution are variable; there is better availability of data in recent decades with increasing lacunae as one moves back in history. Especially difficult are estimations of health conditions during times of political crisis, when data collection systems are disturbed or misrepresented. There is also insufficient transparency and openness of access to data for academic study. We recognize these imperfections, but we believe that our estimations are sufficiently robust to substantiate the basic conclusions. Second, we recognize that China is a vast country with great internal diversity. This chapter focuses only on the national level. The variability within China is recognized; indeed, many estimations of the national pattern are derived from microstudies in China’s different regions. But focusing on the national level better captures the pattern and velocity of change over the course of a century.

Figure 1.1. Life expectancy, China (with Hong Kong and Taiwan) and United States, 1900–2000. Sources: For United States, data from Arias (2010). For China, 1950–2000, data from Peng (1987); Sen (1990); United Nations (2011). For China, 1900–1950, data from Campell (1997); Ni (1986); Rao and Chen (1995); Seifert (1935); You, Quan, and Xu (1991); Zhao (1990). For Hong Kong, data from United Nations (2011). For Taiwan, data from Ministry of the Interior (2011).

Health Transitions

Figure 1.1 charts China’s remarkable achievements in health across the twentieth century. With an estimated average life expectancy of only thirty years in 1900, it is no wonder that China was denigrated as the sick man of Asia. By the end of the century in 2000, however, China’s life expectancy had more than doubled, to an estimated seventy-one years.

The trend line for the United States is shown to highlight the nature of China’s achievements. Whereas China was seventeen years behind America’s life expectancy in 1900, that gap had narrowed to only six years by 2000. Noteworthy is that the gap had widened to twenty-five years at mid-century—China at forty-four years and the United States at sixty-nine years—underscoring China’s stagnated health gains in the first half of the century followed by markedly accelerating improvements in the second half of the century.

For comparative purposes, available data on Taiwan and Hong Kong since 1950 is superimposed on the time trends. Relatively unencumbered by the effects of war, Taiwan and Hong Kong began with a higher life expectancy around 1950 and also performed well in the second half of the twentieth century, even surpassing the United States in longevity (United Nations 2011; Ministry of the Interior 2011).

The weak progress in mainland China in the first half of the century, 1900–1950, was undoubtedly related to political chaos, war, and weak health care infrastructure associated with the collapse of the Qing dynasty, the emergence of the Guomindang, the Japanese invasion, World War II, and the postwar civil conflict. The marked acceleration of improvements characterizing the second half of the century, 1950–2000, was achieved due to political stability followed by strong government commitment to equitable health interventions.

The two phases of retarded and accelerated health achievements match well with the theory of the twin engines of health development: direct health action and social determinants of health. The revolution in health sciences, modern knowledge, its derived technologies, and their application has undoubtedly had an important impact on health conditions. While not dismissing the usefulness of traditional medicine as well as modern, there is strong evidence of the life expectancy impact of the application of modern science through health institutions of hospitals and field-based health systems operated by well-trained modern health professionals. These direct health actions parallel the influence of powerful social determinants. Political stability can enable populations to reduce their risk and vulnerability to disease and provide the institutional foundation for direct health interventions. Economic growth brings not only food, clothing, housing, and other material provisions but the physical infrastructure of health care systems. Perhaps most important among social determinants are universal literacy and education, including gender equality. Literate populations are able to understand and act on theories of disease caution, utilize health services, and adapt their behavior to enhance disease prevention and the use of earlier and more effective treatment.

Four Horsemen of the Apocalypse

Figure 1.1 also shows that, more than any major world country, China has experienced some of the greatest health catastrophes in human history. The four horsemen of the apocalypse describes the major life-threatening crises due to war, famine, disease, and death (Cunningham and Grell 2000). Unfortunately for the Chinese people, the country experienced all four horsemen. We discuss in turn China’s experiences of invasion, war, famine, and epidemics.

Invasion, war, and conflict characterize China’s turmoil over the decade and a half of 1937–1949. In 1937 Japan launched a massive invasion of China called the Second Sino-Japanese War (the first war occurred in 1894–1895). After the Japanese attack on Pearl Harbor in 1941, the invasion became part of the greater conflict of World War II as a major front of what is broadly known as the Pacific War. The conflict did not cease with the surrender of Japan in 1945, as the Guomindang and the Communists fought a protracted civil war in 1945–1949. The official government statistics for Chinese military and civilian casualties in the Second Sino-Japanese War from 1937 to 1945 are twenty million dead and fifteen million wounded (Guo 2005). Other estimates suggest that the total population of about 500 million suffered ten to twenty million deaths, or 2–4 percent of the population (Clodfelter 2001).

Famine, unfortunately, killed more Chinese than epidemics or war in the twentieth century! Indeed the worst famine in recorded history hit China during the Great Leap Forward in 1959–1962. The causes and toll of the famine have received extensive and intensive academic attention (Ashton et al. 1984; Lin and Yang 1998), and excess famine deaths have been estimated at twenty to forty-five million (Peng 1987; Sen 1987). Grain production dropped by 15 percent in one year and then to about 25 percent below its previous level for two further consecutive years. Birth rates dropped by 50 percent and the number of births during 1958–1962 was about thirty-three million fewer than expected. Population annual growth rate dropped from 2 percent in 1958 to negative in 1961 (Ashton et al. 1984). Long term effects were also significant, as fetal and early childhood malnutrition carried adverse consequences for adult health as well as a range of socioeconomic outcomes, including literacy, labor market status, wealth, and marriage markets. An estimated fifteen to twenty years of loss in life expectancy was caused by the famine (Banister 1984; Sen 1990).

The causes of the famine were officially claimed to be natural disasters, including drought and flooding, which had periodically affected China. The bad weather contributed to the significant drop in output (Ashton et al. 1984), but as Amartya Sen points out in his entitlement theory, some of the worst famines have occurred without a significant decline in food availability (Sen 1990). What is important is that affected individuals ceased to have the ability to command food. It is widely accepted that a set of misguided policies in China’s Great Leap Forward played a critical role in the massive food shortage. Especially detrimental were misreports of local food production to demonstrate political correctness imposed by top-down policies irrespective of conditions on the ground—policies for which millions suffered and lost their lives.

The total human toll of all of these health catastrophes over the century will never be known with certainty. What appears well documented is that China’s twentieth century witnessed at least between 45 to 74 million excess deaths due to these disasters.

Disease epidemics have hit China throughout the century, such as the Manchurian plague early in the century, the worldwide influenza epidemic, and SARS early in the twenty-first century. Mortality data on the Manchurian plague of 1910–1911 is limited. The mortality toll of the SARS epidemic of 2003 was miniscule in comparison to its impact on public fears and the paralysis of international trade and commerce. The 1918–1919 influenza epidemic was likely the most deadly infectious crisis in China in the course of the century.

Deemed one of the most devastating