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Full text of "Medicine and public health in the People's Republic of China"

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MEDICINE AND 
PUBLIC HEALTH 

in the 

People's Republic of China 



A Publication of the 
Geographic Health Studies 

JOHN E. FOGARTY INTERNATIONAL CENTER 

for Advanced Study in the Health Sciences 
1973 



Joseph R. Quinn, Ph. D. 

Editor 



U.S. Department of Health, Education, and Welfare 
Public Health Service 
National Institutes of Health 

DHEW Publication No. (NIH) 73-67 



5*1 

13 



TABLE OF CONTENTS 



PREFACE-by Dr. Milo D. Leavitt, Jr v 

INTRODUCTION-by Dr. Joseph R. Quinn vii 

I. CHINESE MEDICINE THROUGH THE AGES 

■vj Traditional Medicine as a Basis for Chinese Medical 

Practices— by Dr. Ralph C. Croizier 3 

j^The Role of the Family in Health Care- 
by Dr. Janet W. Salaff 23 

Surgery Past and Present— by Dr. John Z. Bowers 53 

Acupuncture— by Dr. James Y. P. Chen 63 

N - Pharmacology— by Dr. James Y. P. Chen 93 

II. HEALTH CARE ORGANIZATION AND 

ADMINISTRATION 

Laws on Public Health— by Dr. Tao-Tai Hsia 113 

Health Care for Rural Areas— by Susan B. Rifkin 141 

Medical Personnel and Their Training— 

by Dr. Victor Sidel 153 

The Academy of Medical Sciences— 

by Dr. Richard P. Suttmeier 173 

III. HEALTH PROBLEMS 

Population Dynamics— by Mr. Leo A. Orleans 193 

Nutrition— 

by Drs. Samuel D. J. Yeh and Bacon F. Chow 215 

Infectious and Parasitic Diseases— 

by Dr. Kun-yen Huang 241 

Cancer Research Organization and Preventive Programs— 

by Dr. Haitung King 265 

Mental Diseases and Their Treatment— 

by Ruth Sidel 287 

IV. INDEX 305 



THE PEOPLE'S REPUBLIC OF CHINA: PROVINCES AND AUTONOMOUS REGIONS 




HONG KONG 



PROVINCES: 

1 . Anhwei 

2. Chekiang 

3. Fukien 

4. Heilungkiang 

5. Honan 

6. Hopei 

7. Hunan 

8. Hupei 

9. Kansu 

10. Kiangsi 

11. Kiangsu 

12. Kirin 

13. Kwangtung 

14. Kweichow 

15. Liaoning 

16. Shansi 

17. Shantung 

18. Shensi 

19. Szechwan 

21. Tsinghai 

22. Yunnan 



AUTONOMOUS REGIONS: 

23. Inner Mongolia 

24. Kwangsi-Chuang 

25. Ningsia-Hui 

26. Sinkiang-Uighur 

27. Tibet-Chamdo 



MUNICIPALITIES: 
Peking 
Shanghai 

AREA: 

People's Republic - 3,746,453 sq. mi. 

POPULATION: 

People's Republic - 750,000,000 (Est.) 



IV 



PREFACE 



Although disease, poverty and hunger know no national, po- 
litical or geographic boundaries, attempts to solve these problems clearly 
are based upon different economic and political systems. Despite these 
obvious differences, there is general acceptance of the desirability of in- 
ternational cooperation in support of biomedical research and the de- 
velopment of means for improving the health of the people of all 
nations. 

In 1969 the Fogarty International Center began a series of studies of 
research and health activities in other countries in relation to their 
political and economic structure. The first study dealt with Soviet 
programs in research and public health as they have evolved in the 
political structure established following the Bolshevik Revolution of 
November 1917. 

In late 1970 the Fogarty International Center began a search for in- 
formation about medical and public health activities in the People's 
Republic of China. A long silence has shrouded that nation, which has 
almost one-fourth of the world's population, an ancient and respected 
civilization, and a long and honorable medical tradition. During 1971 
communication between the United States and Mainland China re- 
sumed after a hiatus of more than twenty years. For those who believe 
that the universal desire for health and relief from disease and suffering 
may be the strongest key to peace and international cooperation, it is 
significant and heartening to observe that physicians were among the 
first groups granted permission to visit the People's Republic of China. 

There will be an increasing need to expand our knowledge and un- 
derstanding of medical research activities in this important country. To 
that end, the Fogarty International Center enlisted the services of a 
number of persons whose past and recent experiences form the sub- 
stance of this document. Despite the paucity of primary source material, 



hopefully this work will serve as a base upon which future information 
will accumulate. 

Inquiries concerning this publication should be addressed to Dr. 
Joseph R. Quinn, Head, Geographic Health Studies Fogarty Inter- 
national Center, National Institutes of Health, Bethesda, Maryland 
20014 

Milo D. Leavitt, Jr., M.D. 

Director 

Fogarty International Center 



VI 



INTRODUCTION 



Although there are no exact official figures available on the 
population of the People's Republic of China, the best estimates place 
the figure at between 750 and 800 million. The implications for med- 
icine and public health of such a large mass of humanity living within 
a land area comparable to that of the United States, which has an 
estimated population of 209 million, are very significant. 

When the Government of the People's Republic of China came to 
power in 1949, it was necessary to organize a public health program on 
a national scale. Many infectious and chronic diseases were taking a 
toll of a significant segment of the populace. In order to save time the 
Soviet public health model was adopted with a centralized authority 
and direction, established within the Ministry of Health, with a hierar- 
chy paralleled by the Chinese Communist Party. Western physicians 
and scientists at the Chinese medical schools began to leave the country 
and greater reliance for assistance was placed upon Soviet medicine and 
public health. A biomedical research establishment was also organized 
along the lines of the Soviet Ministry of Public Health and the Acad- 
emy of Medical Sciences. During the 1950s this adaptation of the Soviet 
model was modified, but not to the extent that it was able to erase sig- 
nificantly the impact of traditional Chinese medicine upon the people. 

When Soviet scientific and technical assistance was withdrawn in the 
late 1950s and early 1960s, as a result of the deterioration of interna- 
tional political relationships, the Peking Government was forced to be- 
come more self-sufficient, although it did continue relations with physi- 
cians and scientists of other countries. 

The Great Leap Forward of 1958, initiation of the communes, and 
economic difficulties of the period, made the challenge even more sig- 
nificant. As the more important infectious and parasitic diseases were 
being brought under control, Chairman Mao Tse-Tung launched the 
Cultural Revolution in 1966. Although this upheaval has still not sub- 

vii 



viii INTRODUCTION 

sided completely, it has already had a significant impact upon medicine 
and public health in the country. Mao's exhortation to emphasize 
health service for the rural areas sent thousands of western practitioners 
to the countryside, modified the curriculums of medical schools, placed 
emphasis upon the subprofessional in the delivery of medical care and 
affected the conduct of research in institutions throughout the country. 

In the desire to subordinate the role of the individual biomedical 
worker to society's needs as a whole, almost all professional publications 
ceased. The visit of foreign medical observers to the mainland was also 
halted when the Red Guards started their "cleansing" operation 
throughout the country. Consequently, current knowledge of the medi- 
cal scene in the People's Republic of China is severely limited. In recent 
years scholars of Chinese medicine have had to rely more on the newspa- 
pers and radio broadcasts from the mainland for their information. Al- 
though a small number of American physicians and scientists were per- 
mitted to visit the PRC during 1971, time did not permit a detailed 
examination of the various aspects of medicine and public health 
throughout the entire country. Any review of the status of medicine 
under such circumstances must therefore be done with these limitations 
in mind. 

Inasmuch as the audience for this document is intended to be those 
persons with a general interest in the subject of China medicine rather 
than the biomedical specialist, the lack of confirming evidence by on- 
site observation or experimentation was not considered a deterrent to 
the preparation of this document. The reader must also recognize that 
most of the more recent sources cited by the authors derive from the 
Chinese Ministry of Public Health and reflect the attempt by the PRC 
to obtain maximum publicity concerning Chinese accomplishments all 
of which is designed to encourage other countries to follow the PRC's 
social, economic, and political path. In order to preserve the substance 
of the authors' views, editing of the articles was purposely kept to a 
minimum. Lastly, a number of other medical subjects were considered 
for inclusion in the document, but an adequate amount of information 
was not available to permit the inclusion of such a subject in this report. 
The design of this study was limited therefore not only by the avail- 
ability of source material but by competent reporters as well. 

The presentation of this report is in three major segments, namely, 
Chinese Medicine Through the Ages, which includes those articles 
dealing with the historical development of certain health aspects of 
China; Health Care Organization and Administration, containing ele- 
ments primarily of an administrative nature; and Health Problems, 
which deals with certain major questions facing health administrators 
of the People's Republic of China. 



INTRODUCTION IX 

Dr. Ralph C. Croizier, Associate Professor of History, University of 
Rochester, Rochester, New York, is the author of the first article in the 
first major segment dealing with "Traditional Medicine as a Basis for 
Chinese Medical Practice". Dr. Croizier, who received his doctoral de- 
gree in Modern Chinese History from the University of California at 
Berkely, has devoted a considerable amount of his postdoctoral research 
efforts to the role of traditional medicine in the People's Republic of 
China. His book, Traditional Medicine in Modern China, published 
by Harvard University Press in 1968, which is frequently cited by 
scholars of China medicine, contains more detailed information on the 
subject. 

"The Role of the Family" by Dr. Janet W. Salaff, Assistant Professor, 
Department of Sociology, University of Toronto, Ontario, Canada, ex- 
amines the subject in terms of the sources of data on family life and 
population processes; the relationship of the family to the community; 
the internal organization of the family and the status of generations 
and sexes; the family as a repository of culture; and patient— practi- 
tioner relations and the role of the family. Much of her knowledge was 
acquired not only through the use of Chinese documentation but from 
recent Chinese emigres as well. 

Another historical article in this segment is that by Dr. John Z. Bow- 
ers, President, Josiah Macy, Jr., Foundation, New York, N.Y., who has 
become one of the leading scholars of Oriental Medicine through his 
studies in the Far East and his research for numerous articles on the 
subject. Dr. Bowers traces Chinese surgery from ancient times to the pe- 
riod of acupuncture anesthesia, based on the historic Chinese tradition 
that the human body is a sacred treasure. 

Dr. James Y. P. Chen, currently Director of Medical Research, Cali- 
fornia Medical Group, Los Angeles, California, is the author of two 
companion articles covering the two important aspects of traditional 
medicine, namely acupuncture and pharmacology. A 1941 graduate of 
Peking Union Medical College with postgraduate studies and research 
in pharmacology, Dr. Chen has maintained his interest in Chinese med- 
icine and culture since he immigrated to the United States in 1945. He 
has contributed over 35 articles on the subject of pharmacology to peri- 
odicals and books. In view of the attention accorded to both subjects as 
a result of recent visits by American physicians and scientists, his arti- 
cles are particularly timely. His article on acupuncture describes the 
history of acupuncture, the philosophical basis of Chinese traditional 
medicine, the meridians and acupuncture points, moxibustion and the 
current status of acupuncture and new developments in the People's Re- 
public of China. In his article on pharmacology, Dr. Chen develops an 
historic review of Chinese materia medica, but deals primarily with 



X INTRODUCTION 

pharmacological research and development of herbal and synthetic 
drugs. 

The second major segment of this document deals with the present 
situation in the PRC and is titled "Health Care Organization and Ad- 
ministration". 

Setting the framework for this segment is the article concerning Laws 
on Public Health by Dr. Tao-tai Hsia, who is Chief, Far Eastern Law 
Division, U.S. Library of Congress, and a lecturer on Communist 
Chinese Law at the George Washington University. Dr. Hsia, who ob- 
tained his LLB from National Cheng-chih University, Chungking, 
China, and his Doctor of Science of Law from Yale University Law 
School, has published a number of monographs and articles on various 
aspects of law and culture in the PRC. In his article Dr. Hsia discusses 
54 documents relating to public health, which have been published by 
Peking in the Collections of Laws and Decrees of the Central People's 
Government and Collection of Laws and Regulations of the People's 
Republic of China. Dr. Hsia's description and discussion of the docu- 
ments represents the major commitment to health by the Peking Gov- 
ernment. 

The second article in this segment of the publication, that by Miss 
Susan Rifkin, a China specialist, lecturer in international affairs and 
research fellow on rural health strategies at the University of Sussex, 
Sussex, England, is a continuation of Miss Rifkin's studies in the 
United States on science and health in the PRC. In her article Miss 
Rifkin traces the development of rural health care in China from the 
advent of the Government of the People's Republic in 1949 through the 
Great Leap Forward and the employment of modern and traditional 
health personnel. 

One of the few American physicians to visit the PRC in recent years 
is Dr. Victor W. Sidel, Chief, Department of Social Medicine, Monte- 
fiore Hospital and Medical Center and Professor of Community Health, 
Albert Einstein College of Medicine, Bronx, N.Y., author of the article 
on "Medical Personnel and Their Training in the People's Republic of 
China". Of particular interest are Dr. Sidel's personal observations on 
the current situation regarding health manpower in the PRC and the 
training of the Barefoot Doctor. 

Dr. Richard P. Suttmeier, Assistant Professor of Government, Hamil- 
ton College, Hamilton, New York, is the author of the article on The 
Chinese Academy of Medical Sciences. Dr. Suttmeier, who has written a 
number of articles on science in China, describes the key role played by 
the Academy in organizing, promoting, and coordinating biomedical 
research, including that on traditional Chinese medicine during the 
various periods of stress and strain of the past two decades. 



INTRODUCTION XI 

The final segment of the book deals with those health problems most 
discernible from the literature and by recent visitors to the People's Re- 
public of China. 

Because of the enormity of the question, population dynamics is dis- 
cussed in the first paper. Its author, Mr. Leo Orleans, a China Research 
Specialist at the U.S. Library of Congress, has been a regular contribu- 
tor to a number of newspapers and journals concerning China, popula- 
tion, Asian affairs, etc. His article is adapted from his book titled 
"Every Fifth Child: The Population of China" which is scheduled for 
publication in 1972 by Eyre Metheuen, Ltd., London, and the Stanford 
University Press. Mr. Orleans' article includes a discussion of the im- 
portant 1953 census, the subsequent population registers, policy levels 
in old China, family planning, reactions and results, and some future 
prospects. 

This is followed by the presentation of "Nutrition" by Dr. Bacon F. 
Chow, Professor, Department of Biochemistry, School of Hygiene and 
Public Health, Johns Hopkins University, Baltimore, and Dr. Samuel 
D. J. Yeh, Department of Medicine, Sloan-Kettering Cancer Institute, 
New York. Born in China and trained in the United States, both au- 
thors' knowledge of the Chinese language and literature, as well as 
their research in nutrition, make them particularly well qualified to 
deal with the subject 

A third important problem facing the Peking Government since 1949 
has been infectious and parasitic diseases, which is the subject of the 
article by Dr. Kun-yen Huang, Associate Professor of Microbiology, 
George Washington University School of Medicine, Washington, D. C. 
Dr. Huang, who was born in China, has co-authored numerous scien- 
tific articles of relevance to the subject. In his article Dr. Huang de- 
scribes what he considers to be the ten most important infectious and 
parasitic diseases still prevalent in China. These are: tuberculosis, lep- 
rosy (Hansen's Disease) , trachoma, Japanese B encephalitis, schisto- 
somiasis, malaria, filariasis, clonorchiasis, paragonimiasis and ancylo- 
stomiasis. 

In recent years the Peking Government has emphasized its determina- 
tion to eliminate cancer in the country. Dr. Haitung King, a research 
sociologist with the National Cancer Institute, National Institutes of 
Health, is the author of an article on Cancer Research Organization 
and Preventive Programs. Dr. King was born in China and also re- 
ceived his undergraduate degree there. His graduate studies were done 
in the United States, where he has contributed many articles to the lit- 
erature. The article in this document deals with the organization of 
cancer research, experimental tumors, the role of traditional anti-tumor 
medicine, the anti-cancer shock brigade model, and analysis of micro- 



Xii INTRODUCTION 

scopically examined data, the cancer screening program and survey, pro- 
grams for cancer registry and cancer education and therapy. 

The concluding article of this segment concerning "Mental Diseases 
and Their Treatment" is primarily an account of Ruth Sidel's recent 
visit to the People's Republic of China with her husband, Dr. Victor 
W. Sidel, who is the author of the article "Medical Personnel and 
Their Training" mentioned above. Mrs. Sidel, who has been engaged 
in social work for many years and has examined social work and child 
care in several countries, examines the historical development of theory 
and treatment regarding mental diseases from ancient times to the pres- 
ent day. Of particular interest in this article are her observations on 
the current mental health scene in the PRC, including visits to hospi- 
tals in Peking and Shanghai. 

In reviewing the articles in this document it must be kept in mind 
that the views of the individual authors do not necessarily represent the 
views of the National Institutes of Health, Department of Health, Edu- 
cation and Welfare or any other agency of the United States Govern- 
ment. 

Lastly, the editor would like to acknowledge the assistance of numer- 
ous individuals at the National Library of Medicine and Library of 
Congress, who have made available the source material for many of the 
articles, and many persons who were kind enough to review the docu- 
ments for various purposes including those at the National Institutes of 
Health and in the private sector. A special debt of gratitude is owed to 
the staff of the Fogarty International Center for their assistance with 
the preparation of the document within such a short period of time, in- 
cluding Mark S. Beaubien, M.D., Arthur H. Furnia, Ph.D., Mr. Masao 
Inouye, Lois Meng, Yvonne Daughters, Elsie Fulton, Annette Goldberg, 
Katherine Beck and Alma Barclay. 

Joseph R. Quinn, Ph.D. 



I. CHINESE MEDICINE 

IrlJKOUvjrrl 1 rlE ACx r^o 



TRADITIONAL MEDICINE AS A BASIS 
FOR CHINESE MEDICAL PRACTICE 



Ralph C. Croizier, Ph.D. 



It is an historical truism that every revolutionary regime, no 
matter how radical its plans and passions, must work with what it has 
inherited from the past in building towards its vision of the future. 
This is most obvious in the material sphere. For example, both the 
Russian and Chinese Communist Parties found themselves ruling pre- 
dominantly peasant populations with underdeveloped industry, poor 
communications systems and low levels of education at the starting 
point for their drive to build industrialized socialist societies. But the 
influence of the past is not limited to these obvious legacies. There are 
also its nonmaterial aspects— institutions, attitudes, and customs— in- 
herited and still living, not just among the populace as objects of 
change, but also among the revolutionaries who wish to guide the proc- 
ess of change. 

All this is just another way of saying that, while men need not re- 
main captives of their past, they can never entirely escape its influence. 
The ramifications of this historical conundrum we can leave to the phi- 
losophers. It is our purpose here to show how China's medical past— the 
traditional system of medicine existent in China at the time of the rev- 
olution, its cultural and social position, and attitudes towards it 
among the populace and revolutionary leadership— have influenced the 
new medical system that has been constructed in the People's Republic 
of China. 

First, to the material legacy in medicine that the Chinese Commu- 
nists inherited in 1949. So far as modern scientific medical facilities and 
trained personnel went, it was totally inadequate to the health needs of 
the enormous population. Estimates of the number of modern trained 
physicians in China at the time of the revolution vary, but it probably 

3 



4 MEDICINE AND PUBLIC HEALTH 

was far short of the figure of 20,000 quoted by the Ministry of Health 
in Peking. 1 Even if that figure were accurate, it would leave a ration 
of only one physician for every 26,000 people in China. Similarly physi- 
cal facilities— hospitals, clinics, medical colleges— were inadequate in 
quantity although some, notably the Rockefeller Foundation supported 
Peking Union Medical College, were of excellent quality. On top of 
this, there was a heavy concentration of these medical resources in a few 
major urban centers with most of the vast countryside almost entirely 
devoid of any kind of modern medical care. 

But that near vacuum in modern medicine did not mean that the 
Chinese people entirely lacked medical care, for there was also the tra- 
ditional Chinese system of medicine and its much more numerous prac- 
titioners. Estimates of the number of traditional doctors are even more 
tenuous, partly because of the lack of any definite standards for decid- 
ing who qualified as a physician. By 1955 the Peking government had 
registered 486,700 traditional-style physicians. 2 If every part-time 
herbalist, bonesetter, or acupuncturist were included, the number 
would undoubtedly be much higher. 3 At any rate, it was clear that 
the vast majority of the de facto health care for the population was 
being supplied by the traditional-style medicine and that it would be a 
long time, even just in terms of numbers, before the modern medical 
sector would be able to fill that role. 

There were also the nonmaterial aspects in dealing with this legacy 
from the past in medicine. The vast majority of the Chinese people pre- 
ferred the traditional practices and practitioners to their modern 
counterparts even when a choice was physically and financially possible. 
To be sure, modern medicine had gained considerable acceptance among 
the portions of the population exposed to it since its introduction to 
China about one hundred years previously. But even there it was usu- 
ally a selective acceptance of areas such as surgery where the modern 
physician was demonstrably superior. For other complaints, traditional 
style doctors were often consulted, even by the educated and affluent. 

Thus in establishing a new health care system for the people of China 
the new government had to consider both quantitative factors (which 
included the heavy economic cost of expanding the modern medical sec- 
tor) and the attitudes of the population. Admittedly, this was a govern- 
ment that in many areas would not be too sensitive about challenging 
traditional preferences and attitudes, but in medicine it saw it possible 
to avoid a frontal assault on the old. The how and why of that strategy 
is the main subject of this paper. Before analyzing their medical policy, 
however, it may be useful to sketch in the main features of Chinese tra- 
ditional medicine. 



TRADITIONAL MEDICINE 5 

^The first requirement is to distinguish traditional Chinese medicine 
from the "folk" or "primitive" medicine. 3 Folk medicine— popular 
ideas about the causes and treatment of disease usually with relatively 
simple remedies applied on a generally empirical basis often by non- 
professional practitioners— can be found in every traditional society, in- 
cluding China. But there is also in China what, following Robert Red- 
field, we might call the "great tradition" in medicine as opposed to the 
peasant level "little tradition" in folk medicine. Or, using another dis- 
tinction, we might refer to the traditional Chinese medical "system", 
using medical system to mean a theoretically articulated body of ideas 
about disease causation and treatment contained in a written tradition 
and practiced by men whose knowledge of that tradition causes their 
society to recognize them as medical specialists. This great tradition, or 
medical system, might well be influenced by popular cosmological ideas 
shared by popular folk medicine, and it is also wrong to think of folk 
medicine as a random grab bag of empirical remedies and popular su- 
perstitions without any kind of general ideas, or systems, to it. 4 But 
the distinction is still valid, and useful, if we are to appreciate what 
medicine was in traditional China and what it has become in recent 
times. If the Chinese Communists had inherited only a folk medicine 
from the old society, their problems and possibilities in building a new 
medical system would have been far simpler than has actually been the 
case. 

As for the character of this traditional medical system, it is generally 
comparable with the rational, but pre-scientific, medical systems of 
medieval Europe, classical Islam, or traditional India. Like them, 
Chinese traditional medicine has a predominantly rational theoretical 
basis contained in a large corpus of medical "classics" of great anti- 
quity, and was practiced by a secular class of physicians distinct from 
the common folk medicine practitioners of the society. 

The medical classics which laid down the basic principles of Chinese 
medical theory for the next two millenia mainly date from the Han dy- 
nasty (206 B.C.-A.D. 220). Of these the most important are the Huang- 
ti Nei-ching (Yellow Emperor's Inner Classic), the Shang-han Lun 
(Treatise on Fevers) , and the Shen-nung Pen Ts'ao (Pharmacopoeia) . 
The books are very different in character. 5 The Nei-ching is a theo- 
retical exposition of the basis for health and illness closely related to 
the cosmological ideas which were taking definitive shape in the Chinese 
philosophic period. The book is of unknown date or authorship, the 
present text probably being composed of several parts. Its attribution to 
the Yellow Emperor, legendary culture hero from the dim mists of 
mythical antiquity, served to give it a semi-sacred, "classical" status. 
Apart from the theoretical, or cosmological sections, it also contains the 



6 MEDICINE AND PUBLIC HEALTH 

earliest known explanation of the distinctively Chinese therapy of acu- 
puncture and the principles behind it. 

The other two are more specific, less theoretical discussions more di- 
rectly derivative from empirical experience. The Shang-han Lun is at- 
tributed to a definite historical person, Chang Chung-Ching, a famous 
physician of the Han period. It is a discussion of fevers and their treat- 
ment. The Pen Ts'ao is the earliest of a series of pharmacopoeia de- 
scribing useful medicinal plants, animals and mineral substances with 
notes as to their application. It, too, has a semi-sacred aura from at- 
tributing it to Shen Nung, "The Divine Husband-man," a mythical 
ruler who supposedly taught agriculture to the Chinese people. But, 
unlike the Nei-ching, it was a much more practical text and thus over 
the centuries underwent many more additions as actual experience with 
herbs and drugs added to the materia medica used by Chinese physi- 
cians. This tradition culminated in the massive pharmacopoeia of the 
sixteenth century pharmacologist Li Shih-chen which till the present is 
still the basic reference work for Chinese herbalists. 

Although the pharmaceutical tradition expanded, the Nei-Ching, 
and to a lesser extent the Shang-han Lun, remained less emendable be- 
cause of their "classic" status in a traditional society where the author- 
ity of classical antiquity was especially strong. This meant that, while 
traditional Chinese medicine did not remain static after the Han, it 
did, like Galenic medicine in Europe, remain "backward looking" to- 
wards the sources of classical authority and continued to develop within 
the broad framework of theoretical ideas based on the cosmology of the 
classical period. 

The basic idea behind these may be seen as a homeostatic concept of 
health and disease related to the cosmological ideas of Han philoso- 
phers. Just as equilibrium, or harmony, within an endless cycle of fluc- 
tuating changes is the basic principle of the natural order and of human 
society, so man (the microcosm to the macrocosm of the universe) is 
healthy when his basic life forces are in harmony and unhealthy when 
the harmony is disturbed. This is expressed in terms of the dual forces 
of the universe, yin and yang, and the flow through the body of that 
vital life force, ch'i (sometimes translated as "pneuma"). This ch'i cir- 
culates in accordance with the alteration of "the five productive phases" 
(wood, fire, earth, metal and water— usually rather misleadingly trans- 
lated as "elements," which suggests stability rather than flux). Any dis- 
turbance, and this leaves room for a wide variety of physical and 
psychic causes, leads to illness. 

From this came an acute sensitivity to environmental factors in pa- 
thology and a predisposition towards internal medicine in treatment. 
Thus, drug therapy and acupuncture, both designed to restore internal 



TRADITIONAL MEDICINE 7 

harmony, became the basic therapeutic techniques; surgery the most 
neglected. In diagnostics an elaborate symptomology was devel- 
oped over the centuries placing great stress on the physician's close ob- 
servation of external signs. The basic technique, however, was pulse 
lore which was directly linked to the theoretical assumptions about the 
five productive phases, ch'i, and the twelve meridians through which 
ch'i supposedly circulated. 

To call the traditional medicine empirical because it did not develop 
the experimental and quantifying techniques of modern science is only 
partly true. Many of the practices may have been empirical in origin 
but, as with pulse diagnosis, they were incorporated into the prevailing 
theoretical assumptions of the medical classics. The explanation of why 
that theoretical framework was never shattered by expanding empirical 
knowledge is part of the question why the scientific revolution did not 
first occur in China, which at least up until the fifteenth century ap- 
peared better prepared for it, rather than in Europe. My own personal 
explanation of that very large historical question would, in common 
with Joseph Needham, the leading authority on Chinese science, place 
heavy emphasis on social factors. 6 

Social prestige and economic reward for physicians lay in their iden- 
tifying as much as possible with the classically learned literati who con- 
stituted the social and political elite of traditional China. Hence, the 
reverence for their medical classics, and hence their disdain for any 
work of a manual nature which would identify them with artisans, in- 
stead of scholars. This not only retarded surgery— a messy business 
which medieval European physicians also left to lower class barber- 
surgeons— but also inhibited the whole development of the supportive 
physical and biological sciences which led the the development of 
modern scientific medicine in the West. The title that the upper class 
Chinese physician appropriated to himself Ju-i, "Confucian doctor," in- 
dicates his social aspirations to literati status. By itself medicine usually 
is supportive or adaptive to the prevailing social system. It should sur- 
prise no one that it was not the cutting edge of a scientific break- 
through in traditional China. 

Yet, ironically, the social position of medicine was not very high in 
traditional China. For, no matter how hard he tried to adopt scholar's 
gowns and scholar's airs, the physician who practiced medicine for a 
living was still a specialist and a professional in a society with a deep 
bias toward the general and humanistic in learning. The really presti- 
gious physician, the authentic "Confucian doctor," was no physician 
at all in the sense of being a full-time professional who supported him- 
self by his medical knowledge. Rather, he was a gentleman and a scholar 
who, by reading the medical classics, had acquired the necessary knowl- 



8 MEDICINE AND PUBLIC HEALTH 

edge, but only treated others more or less as an avocation out of purely 
humanitarian and philanthropic motives. The famous Sung dynasty 
philosopher Chu Hsi tellingly remarks of a famous physician: 

Sun Szu-mo was a noted doctor of literature of the T'ang dynasty, but as 
he practiced healing as a profession he was relegated to the class of artisan. 
What a pityl T 

The key phrase is, "as a profession." Scholars might practice medicine 
as a philanthropic hobby and be praised for it; but full-time medical 
specialists were artisans. The best or luckiest of them might achieve 
fame and fortune, but not as a class, or as a profession. As Hue re- 
marked after his travels through nineteenth-century China: 

. . . the profession of medicine is considered an excellent conduit, or waste 
pipe, to carry off all the literary bachelors who cannot attain to the superior 
grades, or pretend to the mandarinate. 8 

The mandarinate, gentry status and government position, was the high- 
est goal. Medicine as a profession was relegated to artisan status, even 
though the efforts of physicians to rise above that status by emulating 
their social betters had all the adverse consequences to the further de- 
velopment of medicine that we have already noted. 

In sum, then, the traditional medical system was strongest in its ther- 
apeutics (especially herbal remedies) and diagnostics, but it was also 
locked into a theoretical and social system that gave it an overall un- 
progressive and unscientific character. Despite attention to many as- 
pects of environmental hygiene, its lack of any germ theory of disease 
made it especially inadequate in dealing with epidemic diseases. No 
modernizing government in China could have found it totally adequate 
for the health needs of the nation, but there were large unresolved ques- 
tions about how much of it could still be useful in the twentieth cen- 
tury. 

But before using this legacy in traditional medicine the new Com- 
munist rulers of China had to come to terms with their own attitudes 
about it. This was not so easy, for since early in the twentieth century 
the traditional medicine had become involved in frequently acrimo- 
nious controversies between radicals and conservatives. As might be ex- 
pected, Western influenced modernists had generally been quite hostile 
to the traditional medicine, seeing it as part of the incubus of unscien- 
tific tradition and superstition that must be removed before China 
could emerge as a modern nation. Conservatives, alarmed by the rapid 
inroads of Western inspired modernity into the traditional culture, 
reacted by identifying the traditional medicine as a valuable part of 
China's threatened cultural heritage. The very name adopted for the 
traditional medical system, Chung-i, "Chinese medicine," underlined 



TRADITIONAL MEDICINE 9 

the new feeling for it as a particular national possession. By the early 
nineteen-thirties defenders of the old system (albeit in an improved 
version) had sharpened the nationalistic connotations of its name by 
referring to it as Kuo-i, "National medicine." Despite the efforts of 
early scientific modernizers, especially modern trained Chinese physi- 
cians, to change this terminology, the terms Chung-i, "Chinese medi- 
cine," and its opposite Hsi-i, "Western medicine," remain in common 
usage and are now taken for granted in the Chinese People's Republic. 

However, an earlier generation of Chinese radicals, including many 
of the founders of Chinese Communism, were not so cool about the se- 
mantic issue or the medical question. Sharing the cultural iconoclasm 
that characterized the radical movement that developed in China after 
World War I, they rejected the old medicine as a particularly noxious 
part of the old culture and society. It was all the more offensive to them 
because its preservation seemed a symbolic rejection of the science and 
modernity which they sought so desperately for China. 9 

But revolutionaries in power, even if only in control over limited 
and rather backward areas of the country, soon find that the responsi- 
bilities of governing interfere with nicely consistent ideological scru- 
ples. This is partly what happended to the Chinese Communists once 
they were in control of rural base areas, first in Kiangsi province and 
later in China's Northwest. There is little surviving evidence of medi- 
cal policy in the Kiangsi Soviet of the early 1930s but what there is in- 
dicates that modern, "Western" medicine was the basis for what orga- 
nized medical care they could provide for the army and the civilian 
population. There were, however, in the face of Nationalist govern- 
ment blockade, efforts made to utilize locally-grown native herbals. A 
decade later in the "liberated areas" of the Northwest this pragmatic 
self-reliance had grown into a conscious policy to use indigenous medi- 
cal resources as much as was consistent with a modern "scientific orien- 
tation". This policy was legitimized at the highest level in Mao 
Tse-tung's famous 1944 speech to the Yenan Conference on Culture and 
Education where he urged modern-trained doctors to unite with and 
raise the scientific level of traditional practitioners in order to better 
serve the people. 10 But, despite later use of the speech to promote tradi- 
tional medicine, there was no indication at the time that any kind of 
equal status was intended with modern medicine. 

After 1949, when they faced the public health problems of the entire 
nation, the new Communist government continued this policy of orga- 
nizing the traditional medical practitioners as auxiliaries to the modern 
medical forces. The paucity of the latter meant that a large part of ac- 
tual medical care still had to be supplied by traditional medicine. The 
organizing and unifying of the two kinds of medicine under the direc- 



10 MEDICINE AND PUBLIC HEALTH 

tion of a Ministry of Health dominated by modern-style doctors seems 
mainly to have been aimed at controling and improving the numerous 
traditional practitioners by giving them some basic modern medical ed- 
ucation while trying to train a sufficient number of modern physicians 
to replace them as soon as possible. In other words, traditional medi- 
cine was a stop gap until it could be replaced by something better. 

To what extent this very second class status for traditional medicine 
was deliberate party policy and to what extent it was the interpretation 
of modern medicine-oriented directors in the Ministry of Health are 
still not entirely clear. There may well have been the same kind of ten- 
sion between the political elite and the health professionals that had 
characterized medical policy under the preceding Nationalist govern- 
ment. But the Communist Party was much less willing to tolerate inter- 
ference from particular groups in society even in their area of special 
competence. In 1954 the Chinese medical world was shaken by a vigor- 
ous Party-led campaign to raise the status of traditional medicine. This 
included denunciation of modern trained doctors and Ministry of 
Health leaders for despising and belittling "the medical legacy of the 
Motherland" and culminated in the purge of key Ministry personnel, 
notably Ho Ch'eng who had been the de facto Minister of Health in 
the first years of the People's Republic. 

Apart from a great deal of glowing publicity for the positive aspects 
of traditional medicine, in concrete terms the new policy caused a sig- 
nificant shift in medical priorities. Traditional doctors were now 
brought into the modern hospitals and clinics with special wards being 
set up for acupuncture and herbal medicine. Modern doctors were 
urged to cooperate with and learn from their traditional colleagues. In 
fact, a whole campaign was mounted to have "Western (modern-style) 
doctors learn from Chinese doctors." For this purpose part-time courses 
in traditional medicine were set up in health units throughout the 
country, but the strongest indication of how seriously the Party took 
this injunction was the selection of 400 modern medical college gradu- 
ates for an intensive three-year course in traditional medicine. When 
one remembers that at this time there could not have been much more 
than 20,000 modern trained doctors in China, it is obvious that the 
Party's announced goal of integrating the two medical systems was 
more than just a slogan. Those in charge of planning allocation of med- 
ical resources obviously thought there was a great deal of value in tradi- 
tional medicine, and for more than just stop gap purposes. 

Another indication of the new importance attached to traditional 
medicine was the opening of facilities for training new traditional-style 
doctors. For this purpose thirteen medical colleges for traditional medi- 
cine had been established by 1958 along with several hundred lower 



TRADITIONAL MEDICINE 11 

schools. But, as earlier reformers of traditional medicine had found, it 
was very difficult to systematize its lore and techniques into a regular 
curriculum. The traditional method of teaching had been through the 
master-disciple relationship and, although the new regime inveighed 
against the selfish and "feudal" aspects of treating medical knowledge 
as a private possession, it accommodated itself to "the apprentice 
method" -in order to train more Chinese-style doctors. With official ap- 
proval and encouragement over 50,000 students apprenticed themselves 
to distinguished traditional physicians. One aspect of educational pol- 
icy towards traditional medicine was to have modern trained doctors 
study it in the hope of producing a new type of combined doctor, but 
the other aspect was to continue producing traditional style doctors 
alongside the graduates of modern medical colleges. The final goal was 
one medicine, and one track in medical education, but for the time 
being the two medicines and two tracks, old and new, were to be con- 
tinued. 

Thus in medical practice throughout China more attention and re- 
sources were given to traditional medicine. This included building 
some special hospitals and clinics for traditional medicine as well as 
creating special wards for it in existing hospitals. In 1955 there also was 
established a large and well-equipped Chinese Medicine Research Insti- 
tute in Peking with a research staff of both modern and traditional doc- 
tors. Branches were set up in most provinces. Party directives carefully 
specified that their work should go beyond a mere analysis of the chem- 
ical properties of native pharmaceuticals. The entire body of tradi- 
tional medical knowledge was to be considered and investigated, for 
"Chinese-style pharmaceuticals are inseparable from Chinese-style medi- 
cine." " In other words, traditional medicine was to be treated as a 
whole, its theory as well as its applied remedies investigated and recon- 
ciled with modern science. The announced goal was a true integration 
of the two systems of medicine, at the theoretical as well as the practical 
level— a higher medical synthesis from the joining of Western and 
Chinese medicine. 

The reasons why medical policy took this sharp turn in favor of tra- 
ditional medicine in the mid-1950s are still open to conjecture. How- 
ever, several relevant factors are apparent. First, there was a general 
return to pride in China's own cultural accomplishments after the 
infatuation with Soviet styles and models in the first few years after the 
revolution. The renewed interest in and praise for "the medical legacy 
of the Motherland" coincided with a nationalistic upswing in fields as 
diverse as theater, painting, and architecture. The strong note of na- 
tional pride running through the pronouncements on Chinese medicine 
was part of this. The fact that medicine was the only area in the whole 



12 MEDICINE AND PUBLIC HEALTH 

scientific realm where Chinese could find something of present-day 
value in their own national tradition gave added force to this. 

But cultural nationalism by itself seems an inadequate explanation. 
One has to ask the question why should Communist revolutionaries 
develop this nationalistic pride in certain aspects of Chinese cultural tra- 
dition at that particular time. General theories about revolutions 
always cooling down and tempering their rejection of the past are help- 
ful. 12 But, in view of such reradicalizing movements in the Chinese rev- 
olution as the Great Leap Forward (1958) and the Cultural Revolu- 
tion (1966), it is hard to see the Chinese Communists as any kind of 
restorationists. My own explanation of the psychological and historical 
factors that permitted Chinese Communist revolutionaries to come to 
terms with these aspects of the traditional culture is that, precisely be- 
cause so much of that old culture and its societal matrix had been 
smashed by 1954, it was possible for a Communist leadership, feeling 
itself securely in power, to select and rehabilitate isolated fragments of 
the traditional culture as parts of the Chinese people's national heri- 
tage. 13 Medicine— because of the Confucian literati's disesteem for 
it as a tradesman's calling— has been relatively easy to identify with the 
healthy elements of the popular culture. When traditional medicine 
stood as part and symbol of a still living traditional society early in the 
twentieth century, revolutionaries had to hate it. With the old society 
destroyed, the revolution triumphant, that psychological compulsion 
was gone and other factors, nationalistic pride and practical needs, 
could influence their attitude. 

The practical needs are obvious in the national sphere— shortage of 
modern medical personnel and facilities, limited economic resources, a 
vast population and many endemic diseases— to which we have already 
alluded. But there were also what might be called practical needs for 
the revolutionary leadership in the ideological sphere within China's 
modern medical profession. To put it simply, the modern medical per- 
sonnel left over from the old society were desperately needed for build- 
ing the new China, but on political or ideological grounds they were 
especially suspect because of the very close association modern medicine 
in China had had with the Western "imperialists". Not only had most 
of the leaders of China's modern medical profession been educated 
abroad, in the United States or Western Europe, but most of the lead- 
ing hospitals and medical colleges in China had been missionary 
founded. Moreover, apart from this past contamination, the Party 
found that the independent professional status of the medical profes- 
sion constituted a challenge to the Party's total leadership of the new 
society. The problem is not peculiar to medicine. It has existed wher- 
ever professional specialists have tried to assert a degree of autonomy 



TRADITIONAL MEDICINE 13 

from the Party's control by virtue of their special competence in a par- 
ticular area. The common expression of this tension is in the terms 
"red" (political orthodoxy) and "expert" (technical competence) . 14 
Whether or not the Party leadership deliberately took traditional medi- 
cine as a means of knocking down the status pride of modern doctors, 
attitude towards traditional medicine did become an ideological ques- 
tion. Medical personnel who resisted the Party's directives to devote 
more attention and more resources to traditional medicine were guilty 
of ideological deviation. The decisive charge against Ho Ch'eng, the 
purged Deputy Minister of Health, was "refuting the ability of the 
Party in the supervision of scientific and technical work". 15 Since 
the mid-1950s traditional medicine has been a political as well as a 
medical question, and any overt criticism of it has understandably been 
muted. 

This does not mean that there were no changes in policy towards tra- 
ditional medicine over the next decade. In retrospect, it appears that 
what the Cultural Revolution identified as "the two lines"— the revolu- 
tionary, populist line of Mao Tse-tung and the revisionist line empha- 
sizing technical and economic progress of Liu Shao-ch'i— were both pres- 
ent in the medical sphere and that their interaction produced many of 
the fluctuations regarding traditional medicine. Thus, praise and sup- 
port for traditional medicine reached its acme during the revolutionary 
zeal of the Great Leap Forward, 1958-1959. The indigenous medical 
system, and especially its popular folkloristic features, fit very well into 
the depreciation of technical expertise at this time. After all, if an engi- 
neer could learn from a coolie, and an agronomist from an old peasant, 
why not have a modern medical specialist learn from a native herbal- 
ist? With the "mass line" in ascendancy, science was no esoteric monop- 
oly of the highly educated few. Enormous numbers of home prescrip- 
tions were collected to prove the wealth of medical wisdom latent in 
the Chinese people and dubious modern doctors were exhorted to use 
traditional remedies in their own practice. For a brief period, research 
articles disappeared from the prestigious Chinese Medical Journal in 
favor of paeans of praise to traditional medicine and the Thought of 
Mao Tse-tung. 

With the retreat from the more extreme policies of the Great Leap 
Forward, emphasis on traditional medicine also declined. By the early 
1960s it no longer dominated medical journals or general publicity 
about China's medical accomplishments. Although courses in tradi- 
tional medicine, especially herbals, remained in the curriculum at 
medical colleges, most medical education seemed to be along modern 
international lines. There were some triumphs for the official policy of 
combining Chinese and Western style medical treatment, notably in the 



14 MEDICINE AND PUBLIC HEALTH 

resetting of fractured limbs with mobile splints. 16 But there was no 
theoretical breakthrough towards a medical synthesis. Modern doctors 
apparently practiced fairly standard modern scientific medicine while 
their traditional colleagues worked mainly along familiar traditional 
lines. As for the combined type doctors, they seem to have largely be- 
come traditional style practitioners. The two track medical situation 
was still in existence and modern medicine was the more important of 
the two. 

But the lessened official enthusiasm for traditional medicine did not 
mean that it ceased to play an important role in providing health care 
for the nation. Admittedly, as the number of modern trained doctors 
rose the dependence on traditional medicine declined, but it remained 
a prominent feature (much commented on by Western visitors) in 
China's urban clinics and hospitals. Its most significant role, however, 
was apparently still in the countryside where "rural health centers" had 
been set up along with the communes in the Great Leap Forward. 
There it continued to provide the bulk of the medical care for the peas- 
antry, while simultaneously absorbing some elements of modern medi- 
cal practice. Although evidence is rather slim, there is some indication 
of considerable cooperation in the day-to-day practice of the two kinds 
of doctors staffing these centers. Usually this has helped the younger and 
more flexible Chinese-style doctors to absorb some of the ideas and tech- 
niques of modern medicine, while the modern doctors could pick up 
from their traditional colleagues some useful medical knowledge and 
even more useful knowledge about handling rural patients. 

Apart from this interchange of knowledge, the integration in the 
rural health center has probably been of considerable adaptive value in 
bringing modern medical care to the villages. Coming in close associa- 
tion with familiar traditional practice, it has probably had to face less 
suspicion and resistance from culturally conservative peasants. Patients 
who might tend to avoid a foreign-style doctor could go to the Chinese 
branch of the clinic where they might obtain some modern medicine 
even from the traditional-style doctor or, if the case merited it, they 
could be turned over to the Western-style doctor. As Robert Worth con- 
cluded in his study of the rural health center in the mid-1960s: "The 
rural health center rode into being on the familiar figure of the village 
boy turned apprentice practitioner." 17 And, as students of medical 
anthropology are well aware, this smoothing of a major cultural transi- 
tion has great advantages. 

In sum, it appeared in the mid-1960s that traditional medicine would 
continue to play an important but auxiliary and, over the long run, 
transitional role in China's medical modernization. Then came the 
Great Proletarian Cultural Revolution. 



TRADITIONAL MEDICINE 15 

As in every other area of Chinese government and society it pro- 
foundly shook the medical world and the policies being followed there. 
In its anti-traditional aspects, the campaign to destroy "the four olds," 
the Cultural Revolution could, and to a certain extent did, prove an- 
tagonistic to traditional medicine. Other parts of the traditional arts 
and culture certainly have not fared well in the last few years. But this 
anti-traditionalism was more than counterbalanced for traditional med- 
icine by the affinity between its popular aspects, especially in their 
anti-expert connotations, and the Cultural Revolution's assualt on bu- 
reaucratic and technical elitism. In spirit, the Cultural Revolution was 
a direct descendant of the Great Leap Forward. Indeed recent accounts 
of the struggle between the two lines in medicine repeatedly refer to 
the innovations of the Great Leap Forward as expressions of the correct 
Maoist line. 18 Thus, white-frocked specialists separated from the 
masses were again under suspicion, and under attack. And with this as- 
sault on public health authorities and Western-style doctors came a new 
assault on modern medicine and a corresponding reemphasis on tradi- 
tional medicine. But, as we shall see, there have been significant differ- 
ences from the revival of traditional medicine in the 1950s. 

The gathering storm of the Cultural Revolution actually affected the 
medical world almost a year before it broke in all its force on the polit- 
ical front. In 1965 Mao Tse-tung himself expressed serious dissatisfac- 
tion with the way medical policy was developing, and under the slogan 
"doctors to the countryside" he personally called for a major reordering 
of priorities. This began the rotating of medical personnel from urban 
hospitals and medical colleges into the countryside as mobile health 
teams. The point was repeatedly made that this would have positive 
ideological consequences for the doctors by exposing them to the rural 
masses as well as medical benefit for the peasants themselves. 

By the summer of 1966, when the Cultural Revolution hit full stride, 
even this corrective therapy for physicians took a back seat to the train- 
ing and publicizing of the "barefoot doctors." The overall role of the 
barefoot doctors in China's public health scheme is discussed elsewhere 
in this volume. Here we are only concerned with how their sudden ap- 
pearance and the general populist thrust of the Cultural Revolution af- 
fected traditional medicine. As the picturesque name given them sug- 
gests, the barefoot doctors are not highly trained medical specialists. 
Rather, they are practitioners with little or no formal medical educa- 
tion recruited on the local level for part-time medical work in their 
own native villages. 19 This means they must rely heavily on local 
resources, both material and intellectual. In medicine, what is available 
at the village-level generally belongs to the traditional medicine. Acu- 
puncture, which does not require expensive modern equipment, and lo- 



16 MEDICINE AND PUBLIC HEALTH 

cally grown herbs, therefore, seem to have been the chief stock-in-trade 
for the barefoot doctors. Though they do not practice purely traditional 
medicine and apparently have only minimal training in its theoretical 
principles, the inexpensiveness, availability and popularity of tradi- 
tional medicine has brought it to the fore once again along with the 
barefoot doctors and rural medical cooperatives of the Cultural Revolu- 
tion. 

The rural medical cooperatives are the main institutional expression 
of the Cultural Revolution's drive for decentralization of bureaucratic 
structures like the Ministry of Health and emphasis on local self-reli- 
ance. Notice of them first appeared in the national press in late 1968. 20 
Organized and financed by either the commune or the production 
brigade, they are local cooperative health systems bringing socialized 
medicine to the countryside for the first time. Members pay an annual 
subscription and then only nominal fees for treatment. Again, local self- 
reliance with minimal dependence upon country or urban hospitals is 
the keynote. In a sense they seem to have grown out of the rural health 
centers of the early 1960s, but appear to be more decentralized in organ- 
ization and rely more heavily on traditional medicine in this practice. 
Evidence is still fragmentary, and there is an urgent need for direct ob- 
servation, but Chinese news accounts suggest that a large majority of 
the patients treated in the countryside receive mainly traditional ther- 
apy. For example, Canton radio reported that as of 1970 "from 70 to 80 
per cent of the cases dealt with by the clinics of the people's communes 
in Kwangtung (province) were treated with medicinal herbs and the 
new method of acupuncture". 21 

Thus, the medical policies of the Cultural Revolution brought tradi- 
tional medicine back into prominence. Throughout the late 1960s 
the medical miracles extolled in the popular press (medical journals 
have been out of publication since 1966) were almost entirely con- 
cerned with acupuncture, herbs, and large doses of the "Thought of 
Mao Tse-tung." Particularly prominent were stories of the miracle- 
working effects of acupuncture when applied by a politically conscious 
practitioner (usually a People's Liberation Army medical corpsman) 
who had learned the art by practicing on himself. The scientific basis 
for all these claims is by no means clear, but the political or ideological 
function— belittling bourgeois specialists and extolling the creative 
power of ideologically inspired masses— was obvious. In a typical case 
story, an Army doctor patiently treats a child paralyzed by polio. The 
case closes triumphantly when "Liu Li-min was able to walk over to a 
portrait of Chairman Mao and, with tears welling up, said: 'The arch 
renegade Liu Shao-ch'i plagued me; it is our great leader Chairman 
Mao who has saved me. When I grow up, I'll serve the people heart and 



TRADITIONAL MEDICINE 17 

soul' ". 22 In the last couple of years, as some of the more extreme 
manifestations of the Cultural Revolution have died down, such en- 
thusiastic testimonials have somewhat declined, although opposition to 
traditional medicine continues to be identified with the arch-renegade 
Liu Shao-ch'i and his revisionist clique. 23 

The position traditional medicine has assumed in the drastically re- 
vised, and apparently still not stabilized health system that has emerged 
out of the Cultural Revolution is far from clear. The curricula an- 
nounced by the reorganized medical colleges all mention acupuncture 
and herbal remedies among the required courses "combining the West- 
ern school and the Chinese school of medicine". 24 Presumably the 
barefoot doctors, being taught at the village level or in rural hospitals, 
get even more of the traditional therapeutics. Similarly, recent reports 
of model hospitals (usually Army hospitals) stress combined treatment 
of diseases using both kinds of medicine 25 . One hospital near Pe- 
king reported that since its founding in 1969, 70 per cent of the cases 
have been given combined treatment. 26 Diseases specifically referred 
to include hepatitis, pulmonary tuberculosis, diarrhea, facial paralysis, 
acute kidney inflammation, tubercular pleurisy, ascariasis of the bile 
duct, phlebitis, severe burns, nephritis, setting of fractures (an old tri- 
umph for "combined therapy"), and the current showpiece of the 
Chinese medical world, acupuncture anesthesia. 

One of the big unanswered questions about this revived prominence 
for traditional medicine is to what extent the original goal of 1955, 
when the Chinese Medicine Research Institute was set up, has been 
abandoned. Then, the theory as well as the techniques of traditional 
medicine were to be investigated and "scientificized" to produce a true 
medical synthesis, not just an appropriation of selected aspects of the 
traditional medical lore by modern "Western" medicine. The extreme 
emphasis on practical experience since the Cultural Revolution, and 
concomitant depreciation of formal research, gives the impression that 
the renewed emphasis on traditional medicine is concerned mainly 
with specific remedies or techniques and not with understanding or 
preserving traditional medicine as a theoretical system. Similarly, the 
publicity for it has not extolled the skill and wisdom of full trained, 
and often venerable, traditional style doctors as it did during the 1950s. 
Instead the heroes have been barefoot doctors or Army medical corps- 
men who, instead of spending long years in assimilating all the princi- 
ples behind practicing traditional medicine, have learned how to prac- 
tice "improved" acupuncture or give certain herbals in the space of a 
few months. The medical populism and distrust of tradition so promi- 
nent in the Cultural Revolution have not been entirely kind to tradi- 
tional medicine as an integral system of theory and practices. In a most 



18 MEDICINE AND PUBLIC HEALTH 

stimulating paper delivered to the Wenner Gren Foundation's sympo- 
sium "Toward the Comparative Study of Asian Medical Systems," Dr. 
Paul Unschuld suggested that the medicine emerging out of the Cul- 
tural Revolution was not traditional Chinese medicine at all. 27 Instead 
the Chinese Communists had found a way to keep its name and appear- 
ance while really training a new force of paramedical personnel who, as 
their standards of training improved, would become more and more 
modern medical practitioners. 

Confirmation of such a view is something that only time, and much 
more direct observation of what is happening in China's medical world, 
will bring. For the present, one cannot emphasize too strongly that in 
traditional medicine, as well as so many other spheres, our knowledge 
of China is far too fragmentary for anything more than educated (and 
sometimes not so educated) guesses. This paper has emphasized 
nonmedical factors— political, ideological, and historical— in discussing 
traditional medicine as a basis for medical practice in Communist 
China. It is not intended to imply that more purely medical, or scien- 
tific, questions about Chinese traditional medicine are irrelevant. But 
other articles in this volume treat those questions in greater detail and 
it has seemed important here to make clear that traditional medicine 
has a long and complicated history of involvement in other than purely 
medical issues. 

When American medical scientists have access to China, traditional 
medicine is likely to be one of the features of China's medical practice 
that will be most shown to them. It is essential that in appraising what 
they see, and are told, they have some understanding of the background 
issues that have influenced the position of traditional medicine in 
China today. Of course, they should take the traditional medicine seri- 
ously. To do otherwise would not only risk missing the opportunity of 
learning something that might be of real scientific value to interna- 
tional medicine, but would also be one of the surest methods imagina- 
ble to block further improvement in Chinese-American relations. Cer- 
tainly medical scientists should maintain scientific objectivity but they 
must also realize that traditional medicine is one area where their 
Chinese hosts, and especially the Communist Party, are apt to be espe- 
cially sensitive. After all, over the last two decades, traditional medi- 
cine has been a sensitive issue in China itself. 



TRADITIONAL MEDICINE 19 

REFERENCES 

1. This figure was given by the Deputy Minister of Health, Ho Ch'eng in 1950. 
"Chung-hsi i t'uan-chieh u Chung-i te chin-hsin went'i" (Uniting Chinese and 
Western-style doctors and the question of improving Chinese-style medicine) 
Jen Min Jih Pao (People's Daily), June 13, 1950. Part of my skepticism about 
this figure comes from the fact that by the outbreak of the Sino-Japanese War 
in 1937 the National Covernment had only registered 9,000 physicians and the 
war years did not witness any enormous expansion of medical training while at 
least some doctors left China before the Communist revolution. 

2. Jen-min Shou tse (People's Handbook). Peking, 1957, p. 608. 

3. The discussion of the history of Chinese traditional medicine in the next few 
pages is derived largely from my book Traditional Medicine in Modern China. 
Harvard University Press, Cambridge, Mass., 1968, ch. 2. 

4. For an interesting account of contemporary folk medicine in Hong Kong see 
Marjorie Topley: "Chinese traditional aetiology and methods of cure in con- 
temporary Hong Kong." Burg Wartenstein Symposium No. 53, Toward the 
Comparative Study of Asian Medical Systems. 

5. Of these only part of the Nei-ching is available in English translation. Veith, 
Ilza, trans.: The Yellow Emperor's Classic of Internal Medicine. Johns Hopkins 
Press, Baltimore, 1949. 

6. A recent collection of Needham's essays may be found in Needham, Joseph: 
The Grand Titration. University of Toronto Press, Toronto, Ont., 1969. 

7. Wong, K. Chimin and Wu, Lien-te: History of Chinese Medicine. Tientsin, 
1932, p. 55. 

8. Hue, Evariste Regis: Christianity in China, Tartary and Thibet. London, 1857, 
vol. 3, p. 209. 

9. This earlier controversy plus the development of traditional medicine in Com- 
munist China is treated in detail in my book. Readers seeking references and 
more information on many of the points made in this article are referred to it. 

10. Mao, Tse-tung: Selected Works. Foreign Languages Press, Peking, vol. 3, 1965: 
236. 

11. Tsing Tao Jih-pao (Tsingtao Daily), Dec. 12, 1954. 

12. I am thinking here particularly of Crane Brinton's well-known essay The 
Anatomy of Revolution, Ed. III. Random House, N.Y. 1965. 

13. This thesis is argued most persuasively in terms of "museumification" of tradition 
in Levenson, Joseph R.: Confucian China and its Modern Fate, University of 
California, Berkeley, California, vol. 3, 1965. 

14. One of the best accounts of this tension in Chinese Communist society is 
Schurmann, Franz: Ideology and Organization in Communist China. University 
of California, Berkeley, California, 1965. 

15. Jen, Hsiao-feng: "Criticize Comrade Ho Ch'eng's Error in his Policy Towards 
Chinese Medicine," translated in Union Research Service, June 8, 1956, vol. 30, 
no. 20, pp. 287-288. 

16. Fang, Hsien-chih: "The Integration of Modern and Traditional Chinese Medicine 
in the Treatment of Fractures," Chinese Medical Journal 82,; 493-504, August 
1963. 

17. Worth, Robert: "Institution Building in the People's Republic of China: The 
Rural Health Center." East-West Center Review 1.3, Feb. 1965, p. 28. 

18. "Guide the Union of Chinese and Western Medicine with the Thought of Mao 
Tse-tung," Kuangming Jih-pao (Kuang-ming Daily) Oct. 30, 1970, translated in 



20 MEDICINE AND PUBLIC HEALTH 

Survey of China Mainland Press. United States Consulate, Hong Kong, 4776: 
48-52. 

19. "The Orientation of Revolution in Medical Education as Seen from the 'Bare- 
foot Doctors,' " Hung-ch'i (Red Flag) Sept. 1698, translated in Selections from 
China Mainland Magazines, United States Consulate, Hong-Kong, 628: 3-9. 

20. Jen-min Jin-pao (People's Daily) Dec. 5, 1968, translated along with other news- 
paper articles in Current Background. United States Consulate, Hong Kong, 
872, Feb. 28, 1969. 

21. Survey of China Mainland Press, 4695: 25. 

22. "Chinese Army Doctor Cures After-Effects of Infantile Paralysis." Current Back- 
ground. United States Consulate, Hong Kong, 70-10, 909, p. 19. 

23. Survey of China Mainland Press, (new numbering system) 71-29; 59-67, July 
1971. 

24. Survey of China Mainland Press. 4459: 4, July 1969. 

25. Survey of China Mainland Press (new numbering system) 71-29; 59-67 and 68-73. 

26. Survey of China Mainland Press. 71-29: 68. 

27. Unschuld, Paul: "The Social Organization and Ecology of Medical Practice in 
Taiwan." Burg Wartenstein Symposium No. 53, Toward the Comparative Study 
of Asian Medical Systems, p. 29. 



TRADITIONAL MEDICINE 21 

BIBLIOGRAPHY 

Ch'en Pang-hsien: Chung-kuo i-hsueh shih (A Medical History of China) Shanghai, 
1937, revised editions, Taipei, 1956 and Shanghai, 1957. Still the most com- 
prehensive and reliable general history of Chinese medicine. 

Croizier, Ralph C: Traditional Medicine in Communist China: Science, Communism 
and Cultural Nationalism. China Quarterly, 23: 1-27, July-Sept. 1965. Similar to 
last chapter of the following, but shorter. 

Croizier, Ralph C: Traditional Medicine in Modern China: Science, Nationalism, 
and the Tensions of Cultural Change. Harvard University Press, Cambridge, Mass., 
1968. Main emphasis is on cultural and political factors affecting controversy over 
traditional Chinese medicine since early twentieth century, but also has chapters 
on history of Chinese medicine, introduction of modern medicine, and medical 
policy of the Chinese People's Republic. 

Leslie, Charles, editor: "Toward the Comparative Study of Asian Medical Systems." 
Forthcoming. Papers from Burg Wartenstein Symposium no. 53, Aug. 1971. Papers 
on Chinese Traditional Medicine by Unschuld, Porkert, Topley, Otsuka, and 
Croizier. Probable date of publication late 1972. 

"Mass Revolution in Public Health," Current Scene, 6, 7, May 1, 1968. Discusses 
Cultural Revolution's impact on health system. 

Needham, Joseph: The Grand Titration: Science and Society in East and West. 
University of Toronto Press, Toronto, Ont., 1969. A collection of Needham's 
essays about science in premodern Chinese history. 

Needham, Joseph: Science and Civilization in China: History of Scientific Thought. 
Cambridge University Press, 1956, vol. 2. The most general volume of Needham's 
massive multi-volume history of Chinese science. It has not yet reached the 
volume on biological and medical sciences which will make most of the English 
literature in the field obsolete. 

Unschuld, P. U.: Die Praxis des Traditionellen Chinesischen Heilsystems Dargestellt 
unter Einschlus der Pharmazie an der Heutigen Situation auf Taiwan. Munich, 
1971. Although discussing state of traditional medicine on Taiwan, has much of 
comparative interest for developments in Communist China. 

Veith, Ilza: The Yellow Emperor's Classic of Internal Medicine. Johns Hopkins 
Press, Baltimore, Md., 1949. Translation with commentary of main section of the 
most ancient and influential of the Chinese medical classics. 

Wong, K. Chimin and Wu, Lien-te: History of Chinese Medicine. Tientsin, 1932. 
Unsatisfactory in many respects but still most comprehensive history of Chinese 
medicine available in English. 



THE ROLE OF THE FAMILY IN HEALTH CARE 



Janet W. Salaff, Ph.D. 



INTRODUCTION: HOW DOES THE ROLE OF THE FAMILY 
FIGURE IN HEALTH BEHAVIOR? 

In their exploration of social and cultural factors related to 
health care sociologists have examined the role of the family from two 
main angles: as an agent in the etiology of disease, and as a unit in 
medical treatment. 1 The institution of the family provides a broad 
context in which the theories of the single vector or the germ theory 
of disease can be placed, thus significantly adding to our understanding 
of health and illness. An examination of the Chinese family— its posi- 
tion in the community, its internal organization and culture— should 
prove useful in comprehending disease causation, prevention, and cure 
in the People's Republic of China. 

One main reason for concern over the part played by social factors in 
the contraction of disease is the apprehension that the prevalent and 
often fatal illnesses bringing people to medical facilities in North 
America are no longer chiefly epidemic and contagious diseases, but the 
chronic and mental illnesses that resist direct attack on the vector, or 
where the vector is unknown. These diseases often have social roots. 
The family as a social institution may "cause" illness in two ways. 2 As 
a system of interacting personalities, the family may create a stressful 
environment which renders members unfit to resist disease. Second, the 
family is an intervening variable, passing on culture and poor living 
circumstances (cultural determinants have been suggested for higher 
rates of some diseases among the poor). 3 Therefore, the role of the fam- 
ily is important in grasping the etiology of disease. 

Second, the characteristics of the family have a bearing on the effec- 
tiveness of treatment. The family is a problem-solving system, yet some 
people search out services to cope with illnesses and others become re- 

23 



24 MEDICINE AND PUBLIC HEALTH 

signed to low levels of health. Hence, many diseases of the poor remain 
"hidden" and do not receive treatment at all. 4 To overcome the inequi- 
ties of medical care, the quality and organization of medical treatment 
is being scrutinized in North America, and the family has become a 
unit of treatment. In attempting to improve poor people's access to med- 
ical services, the O.E.O. began to train community health workers to 
serve in their own neighborhoods, where they would be quick to spot 
certain kinds of illness endemic to their area and successful in treating 
it. 5 It was also found that care improved when medical workers kept 
case records of and treated entire families. 6 If the culture of the area 
were taken into account, medical care could become more accessible 
geographically and psychologically to diverse social groups. 

Questions related to the organization of medical care in China also 
bear on the role of the family. The accomplishments of two decades of 
attack on communicable and epidemic diseases 7 have shown that cer- 
tain chronic and degenerative illnesses persist at higher rates among 
certain regions and classes. In China, too, a lively discussion is under- 
way on the contribution of local culture to preventive and curative 
techniques. Prevention of illness is stressed, involving social institu- 
tions, for instance, in organizing community sanitation drives to pre- 
vent endemic parasites. Methods of organizing and financing medical 
care for the community are being debated. To what extent should med- 
ical workers enter into the overall context of peasant life or treat citi- 
zens in a narrow capacity as healer? An examination of the functions of 
the Chinese family in the community and the strength of family cul- 
ture should shed light on the social context of illness and medical care. 

Towards this end this discussion of the role of the family has been 
organized into five sections: 

1) Sources of data on family life and population processes. 

2) The relationship of the family to the community. To what extent 
is the family in rural and urban China still a unit that fills numerous 
functions which are not performed by the community? Or, has the fam- 
ily become an institution which is a buffer to the community; in this 
sense does it simply mediate outside services while the community per- 
forms manifold production and consumption activities? 

3) Internal organization of the family and the status of generations 
and sexes. An analysis of the changing status of youth and women in 
the Chinese family should prove useful for a broader understanding of 
trends in health and welfare. The rising position of youth and women 
appears related to levels of health both as independent and dependent 
variables. The historical experience of European society has shown that 
declining infant and child mortality leads to a change in the status of 
youth. 8 When they no longer fear their children will die, parents can 



THE ROLE OF THE FAMILY 25 

afford psychologically to invest emotional commitment in them. The 
emergence of the period of youth as an important social status appears 
in turn to have contributed to improvement of health care. The profes- 
sionalization of occupations, including the medical profession, has been 
connected with emphasis on learning as an attribute of youth, and de- 
cline of the monopoly of knowledge by the elders. 

The status of women in the family has also had a bearing on social 
health and welfare. Bierman has observed that major changes in legisla- 
tion of significance to maternal and child health both within the indi- 
vidual states of America and among the nations of the world have 
tended to follow the introduction of women suffrage. 9 Knutson hypoth- 
esized further that this was perhaps due to the stronger religious, es- 
thetic, and social value orientations of women that were given political 
importance after suffrage. Their greater independence and higher edu- 
cational levels have also been accompanied by improvements in child- 
rearing practices, with implications for the health of mother and 
child. 10 This section asks how does the Chinese family structure the so- 
cial roles and statuses of its members by sex and age? To what extent 
has the prestige of youth and women increased? 

4) The family as repository of culture. As one gateway to culture the 
family plays an important role in defining illness and mediating access 
of its members to such care that exists. Since "health" and "disease" are 
concepts which vary from culture to culture, the family passes on expla- 
nations of the causes and cures of what it defines as illness to members. 
Like other peasant societies, 11 the Chinese culture has a three-fold clas- 
sification of illnesses and their cure: trivial every-day complaints may 
be treated by home remedies; "European diseases," such as measles and 
malaria, respond to Western scientific therapy; specifically "Chinese dis- 
eases" which are not likely to be understood or treated successfully by 
Western medicine may be treated by traditional doctors. 12 The search 
by family members for a cure will be mediated by the definition of the 
disease, and the family plays an important role in this regard. This sec- 
tion will deal with the family as repository of culture. Does the pre- 
Communist folk culture continue to dictate the behavior of peasants, 
perhaps underlying their more sophisticated veneer of modern vocabu- 
lary and dialectical thinking? 

5) Patient-practitioner relations and the role of the family. The 
trend in Chinese society is to increase the role of the community in 
providing its own health care, reducing the part of the isolated family 
and of the professions. How does the family unit figure in the "thera- 
peutic relationship"? To what extent does the family still influence its 
members to serve in the health professions? 



26 MEDICINE AND PUBLIC HEALTH 

SOURCES OF DATA ON FAMILY LIFE AND 
POPULATION PROCESSES 

Information on the role of the family and its relationship 
to medical services can be obtained from four sources: press accounts 
of current health-related events, travellers' reports, data from medical 
research journals, and interviews with former mainland residents. 

Press reports. The purpose of the Chinese press is didactic. 
Its main aim is not to report events, but to direct and exhort and to 
create confidence in current political movements. The selective cover- 
age poses a key problem to the researcher trying to ascertain the reli- 
ability of press accounts. The focus is often on "models" to be emulated, 
and this means that average cases or failures in any social experiment 
are less likely to be discussed. Likewise, the differential responses of 
various social strata to campaigns are rarely compared. 

The political climate in China may also lead to misreporting; this 
calls into question the validity of information received from the press. 
Purposeful falsification is more likely when the careers of local leaders 
depend on the outcome of events that are reported. 

The chief method of checking both the reliability and validity of the 
press is to draw on a variety of sources reporting the same events. On 
some issues the press covers the responses of a variety of social groups 
and geographical areas. The discussion of the introduction of the Mar- 
riage Law in the early 1950s was one example. A shift in political cli- 
mate, such as the Cultural Revolution, may spark criticism of past re- 
ports. Internal documents criticizing policies may occasionally come to 
light. Numerous useful studies on the Chinese family have therefore 
drawn on press reports. One of the best is that of C. K. Yang, The 
Chinese Family in Communist Transition.™ 

Travellers' tales. Press items can also be compared to travel- 
lers' tales, although this information must also be treated with caution, 
since the government often arranges the places to be visited by outsiders. 
Useful monographs dealing with family life have been written by for- 
eign visitors or habitants of the PRC. William Hinton's study, 
Fanshen, provides a clear picture of peasant life in the liberated areas 
of northern China pre-1949. W. R. Geddes {Peasant Life in Commu- 
nist China) restudied a village in the Yangtse River delta in 1956; it 
had previously been studied by Fei Hsiao-t'ung in the 1930s. The 
Myrdals in Report from a Chinese Village and China, the Revolution 
Continued discussed the lives of the habitants of a northern village 
visited in 1963 and again in 1967. Isabel and David Crook (The First 
Years of Yangyi Commune) are two European residents of China who 
restudied a village after several decades. 

Only one of these works, that by Geddes, took a "census'' of a cooper- 



THE ROLE OF THE FAMILY 27 

ative; the Myrdals inventoried household expenditures. But the politi- 
cal atmosphere since 1962 has made it more difficult for visitors to col- 
lect data systematically from the local registration system, or from 
house to house surveys. Travellers' tales suggest ideas, but provide frag- 
mentary evidence at best. 

Population surveys and medical research journals. The 

greatest deficiency for the social scientist studying China is the lack of 
demographic data. The Chinese do not now participate in international 
data banks nor do they publish their census tabulations or registration 
data. 14 It may be argued that the government has not released pop- 
ulation data because of their low quality. Just as likely, the officials are 
concerned with the political implications of publicizing population size, 
distribution, and composition. The 1964 "census" results have not been 
revealed, although the quality is probably higher than that of the 
1953 census. 

Specialized journals on medicine publish some biostatistical mate- 
rials that can be used in studying demographic processes and disease 
rates. The U.S. National Library of Medicine has collected a series of 
regional and national medical journals from the PRC. Their publica- 
tion ceased during the Cultural Revolution. I have suggested elsewhere 
that such surveys do provide reliable and valid data on epidemiology, 
and on adoption of contraceptive techniques. 15 

Interviews with former mainland citizens. This paper, 16 
as well as other studies, 17 draws on interviews with recent emigres 
from the mainland. Although most respondents were from southern 
China, both rural and urban areas and all social strata were repre- 
sented. Both married and single people were interviewed. Emigration 
from China after 1964 was more difficult than during the previous 
three years, and the fact that respondents took this difficult course 
often affected their family relationships, a topic dealt with in this paper. 
Some postponed marriage until after the move, while others found that 
family demands on them were different than if they had planned to 
remain in China. 

Why did they migrate? Any one migrant has several reasons for leav- 
ing China, but general patterns of decision-making emerged. Most 
wanted a higher standard of living or different career pattern than they 
thought available to them in China. Many also had a political stigma, 
which would have blocked advancement in their careers or political sta- 
tus. 

Readers may suspect that the fact that informants were refugees and 
often political pariahs colored their information. I do not believe that 
this was the case. Refugees expressed as many different opinions toward 
the government depending on their past class background and their 



28 MEDICINE AND PUBLIC HEALTH 

perceived economic prospects as did Overseas Chinese. While a minor- 
ity were bitter, many others showed pride in the accomplishments of 
the PRC. Respondents were also willing to discuss sources of their atti- 
tudes toward the country left behind. Far more critical for a study of 
family relationships is the cultural prohibitions against frank discus- 
sion of actual family behavior and relationships. Visitors to the PRC. 
often bring back reports of family life from discussions with citizens; 
such reports often describe the cultural ideal of the family life, rather 
than descriptions of actual behavior. The problem is magnified when 
interviewing Emigres outside of their homeland; an extended stay doing 
participant observation may be the sole method of gaining deep under- 
standing of family life in China. 



THE FAMILY AND THE COMMUNITY 

The Family as an Institution: Background 

The nuclear family has not been eliminated, but from various 
sources of data it can be surmised that numerous reforms have weak- 
ened the family as an independent institution. The dynastic pattern 
of limited state rule at the village level had allowed families to assume 
political functions. After 1949, in contrast, the village was penetrated 
and reorganized along new lines. This brought about alterations in 
family structure and in the quality of relationships between genera- 
tions and sexes. 

In the areas in which it held power before 1949, the Chinese Com- 
munist Party instituted programs aimed at destroying the political 
power of the lineage. Two important reforms were carried out: land re- 
form and implementation of the marriage law. Land reform handed 
out land deeds to every man, woman, and child, thus removing the 
property base from the family and lineage. Marriage reform was a nec- 
essary concomitant. Only if the family lost its power to arrange the mar- 
riages of the offspring and to charge high sums of money for a daugh- 
ter's hand would women be free to assume land ownership. The 
Marriage Law of 1950 (the latest of several versions) established freedom 
of marriage and of divorce and gave equal rights in marriage to men 
and women. Marriage was founded in the interest of the two parties, 
not in the interests of their families. After these two reforms, the legal 
and economic basis of the joint household of the wealthy was destroyed. 
This was an important step in changing the political system. 

To what extent is the Chinese family evolving along the path— "from 
patriarchy to companionship"— taken by North American families? The 
"companionship family" refers to a unit which takes charge of procrea- 



THE ROLE OF THE FAMILY 29 

tion, early socialization, consumption, and mediation between outside 
institutions and family members; it serves to provide an emotional 
haven from outside pressures for competition and achievement. This 
family type emerged with the mature industrial state in the West. 
China, however, is in the developmental phase of industrialization, in 
which society's resources are channeled into capital accumulation in- 
stead of social services and consumer goods. As a result, a dominant fea- 
ture of the rural Chinese environment is the low level of social services 
when compared with the urban way of life. 

The concept of the "transitional society" may be more useful for un- 
derstanding the community which shaped the kinship institution in 
China. This type of society is characterized by rapid social and eco- 
nomic change and families with numerous children. Few extrafamilial 
services exist to supplement the family's functions. Thus, it performs a 
multitude of services in regard to: production; political activities and 
allocation of status; child care, socialization, and training; maintenance 
of health and welfare of family members; and care of the elderly. In the 
following pages it will be argued that the rural family, comprising the 
bulk of the population, remains a significant social and cultural institu- 
tion in Chinese society, and it cannot be characterized as a companion- 
ship family. 

FUNCTIONS OF THE FAMILY 

Economic functions. In sociological terms the reforms of 
rural production in the first decade after liberation transformed the 
villagers from peasants to "rural proletarians". 18 After land reform 
was completed in 1952, land was collectivized (1955-1957) . Today the 
peasants live in "people's communes", administrative and productive 
units owned collectively by the people, in contrast to state farms which 
are owned by the state. Communes provide the basic grain crops 
needed for the members' livelihood. Many also supply cash crops to 
the state. The populace is now more closely involved in a market 
economy. Alienated from land ownership, they view land as a means 
of production as would a factory worker; it is not a family possession. 
Members work the land in teams with other villagers of equal ability 
and strength, rather than with their own family members. Now the 
family no longer forms a single production unit. 

Yet the transformation from farm to rural factory labor has not been 
complete. Peasants do not receive a uniform predictable wage; they are 
not unionized. The wage of the individual is calculated in work points 
allotted on the basis of days worked, and the amount of strength and 
skill the job requires. But income also depends on the productivity of 



30 MEDICINE AND PUBLIC HEALTH 

the land and the year's harvest. The income of the peasant farmer is 
low, ranging from 127 yuan* to 330 per capita per year. 19 In contrast, 
the average factory worker's wage is 50 yuan per month or 600 yuan an- 
nually. The family cannot predict its income from the collective from 
year to year. This is not to say that rural families verge on starvation. 
However, the sources of their incomes remain uncertain and varied; 
they depend on the collective for grain and on their own tiny vegetable 
plots or household handicrafts and livestock and poultry for food and 
cash. 

In the past the household head (chia-chang) controlled and managed 
the family property. Restrained by the 1950 Marriage Law, the patri- 
arch's right to control his family's economic future still continues in 
custom to some extent. An average peasant family requires the earning 
of at least two adult members. Although they earn their income as indi- 
viduals, all members of the household must contribute their income to 
the family purse. In interviews of former peasant families, it was found 
that young adults still handed over all their earning to one household 
"manager". Usually, the eldest woman, the wife of the grandfather, man- 
ages the expenditures and income of the family, giving her considerable 
power over the occupational choices of the offspring. If the labor of all 
children cannot be spared, family meetings may be held to decide 
which has the opportunity to continue school. 20 The occupational fu- 
ture or the marriage prospects of the boys or girls may be discussed 
because it is a factor in the economic situation of the family. Political 
education sponsored by the Communist Party has countered the single- 
minded concern for offspring to achieve. Nevertheless, parents insist 
that their children achieve in school in order to raise the position of 
the entire household. No longer prescribed by family law, a collectively 
managed household economy is nonetheless critical for the rural fam- 
ily's survival. 

The household is a production and consumption unit. Families still 
perform the essential role of maintaining and rearing workers for pro- 
duction; this has not been taken over by the community. Without out- 
side agencies to perform household work and to provide labor-saving 
devices for the home, upkeep of the household is time consuming. The 
women do the marketing and prepare the food. The absence of refriger- 
ation and packaged food means the housewife must spend time daily 
and each season in producing, salting, and putting away vegetables. 
Canteens can be found in urban factories; in rural areas mess halls 
exist only at harvest time. Housework is performed by each family. 
Mothers sew some of the clothes, although cheap work clothes and shoes 
can be purchased. The sewing machine is a prized possession. Thus the 



"One yuan = 42<£ U.S. 



THE ROLE OF THE FAMILY 31 

rural family remains a production unit manufacturing rather than pur- 
chasing much of what it consumes. 

Changes in the collective economic structure have affected the fam- 
ily's range of decisionmaking. Money can be borrowed from the com- 
mune bank for necessities, and villagers need not depend on personal 
relations or money-lenders. The family head cannot pass on his job to 
his offspring, nor can he decide the precise jobs his child will take; but 
he will teach his children an orientation to succeed. He cannot reinvest 
any surplus profit earned by his son's labor or from the sale of private 
produce. Neither will the family be driven into starvation should mem- 
bers of the household fall ill, or should the family enter the stages of 
family formation which have a high ratio of dependent to productive 
members, such as numerous small children and aged adults to workers. 
In such cases, the commune may help out with a small welfare subsidy. 
Despite these changes as a rule the peasant family cannot earn enough 
to survive the continued disability or death of its main breadwinner. 
Kinship ties in rural China remain closer and more supportive than in 
the cities because the limits of the farm economy, which are felt less 
severely in urban centers, require the family's filling important produc- 
tion and economic functions. 

Political-legal functions. The traditional Chinese family, 
not the individual, was the basic political unit for all social classes in 
Confucian China. The families in the village aggregated into lineages 
(popularly called clans) , which drew up laws. They held court and 
used social pressure to gain adherence to these laws which were largely 
moral injunctions to the family members to behave properly. Only if 
the elders failed to control the kinsmen would the relatively small 
number of imperial officials at the county seat take over, an occurrence 
which all parties tried to avoid. The state ruled passively; minimal 
compliance and payment of taxes was all it demanded from its citizens. 
Even among the poor, family members were held responsible for one 
anothers' debts and crimes. 

Under socialism the individual is to be incorporated gradually into 
collective life. As one form of a collective, the family is accorded some 
political functions, the most important of which are political analysis, 
mobilization, and the assumption of collective political responsibility. 

Since family members share the same social class, no generation gap 
is expected in values and attitudes of younger and older household 
members. Contradictions are recognized within the family as emerging 
from different social outlooks resulting from patterns of life experience. 
Offspring of proletarian and poor and lower-middle peasant parents 
must educate their elders respectfully into the proper political views. 
Youth thus have an obligation to discuss and resolve political differ- 



32 MEDICINE AND PUBLIC HEALTH 

ences with their parents, following the new standards of Mao thought. 
An upsurge of Mao Tse-tung thought study classes held in the family 
reflects the belief that even family problems are amenable to political 
analysis. Mao's thought is a flexible yet general measure against which 
the contradictions in the family can be analyzed. 21 The youth need not 
break with their proletarian family members, but should win them over 
through discussion and analysis. 

Taught that the collective's property is more important than that of 
the family, the young people partake in mobilizing family members to 
work for the collective without remuneration. 22 This can be seen in 
such mundane activities as raising an extra pig for the collective with- 
out charge, working overtime or serving as a cadre with low pay in 
place of doing handicraft work at home, or using spare time to clean up 
sanitation ditches during "patriotic public health campaigns". 

Family members share collective political responsibility. In contrast 
to the Soviet view that spouses are not liable for each other's political 
attitudes, 23 in China a husband must assume responsibility for his wife's 
political participation and children assume this responsibility in regard 
to their parents. 24 An individual also bears the political status or label 
of his family. The family class label such as "poor peasant", "middle 
peasant", "landlord" status was set during land reform, based on the 
family's relationship to the ownership of the means of production at 
the time. 25 This label is inherited and cannot be changed. The pariah 
son of a formerly exploiting social class can be educated into new atti- 
tudes, but he may have to prove them by opposing parental misdeeds 
and leaving the family. 26 This is a difficult act, since the family depends 
on their offspring's labor for survival. The need to draw a clear line be- 
tween a person's parents and his own political views requires frequent 
reexamination of his political attitudes. The youth remain vulnerable 
to their family's political background and in tension with them at the 
same time. The collective family responsibility may be related to the 
low level of economic development where one's occupational position 
remains identified with that of one's parents. 

The Large Family System 

The large number of functions performed by the rural 
family results from the "large family system" which, as described by 
Bossard and Boll, refers to a nuclear or stem family with numerous off- 
spring in industrial society, 27 not the joint household composed of 
several nuclear units of traditional China. The former sizeable family 
required an extensive division of labor to perform its many tasks, such 
as clothes making, food preserving, child care, and babysitting, that in 
smaller urban families might be performed by outsiders. A considerable 



THE ROLE OF THE FAMILY 33 

proportion of Chinese families now have such large family systems. A 
survey taken in China in 1959 found the average number of children 
ever born to women aged 45 to 49 was 5.3 for urban families and 7.3 
for rural families; women aged 35-39 had borne an average of 4.9 and 
6.2 children respectively. 28 This is a result of the family and commun- 
ity expectations which structured incentives for childbearing, encour- 
aging families to bear many offspring; because of past high mortality 
only a few were expected to survive. 

Since infant and child mortality has dropped sharply, it can be pre- 
dicted that the numerous children borne in the 1950s would survive. 
Fertility decline generally lags behind mortality decline. Some time 
may elapse before fertility drops to meet mortality levels, a process 
known to demographers as "the demographic transition". Although the 
second generation born under the new regime may well lower their 
family size in contrast to their parents, 29 their own families of orienta- 
tion (their parents and siblings) are generally large. 

Large households require the youths' active participation in their up- 
keep. They must be willing to perform many of the tasks their mothers 
might have done in a smaller home. Housework, care of younger sib- 
lings, care of the ill, and farm tasks are responsibilities for the children. 
Siblings of distant ages take on parent and child roles, and those of ad- 
jacent ages are close friends. Large families also share numerous rituals 
and extensive family histories. Such a family feels crises severely. When 
members are ill, they spread illness. If the breadwinner dies the family 
and relatives step in to help or otherwise the others are plunged into 
poverty. The commune provides only a modicum of welfare services. 
The large family system is a product of the "transitional society" in 
which birth rates remain high although mortality has declined, and 
family ties are strong out of necessity for common survival. 

Childbirth, Child Care, Early Socialization, and Education 

As in other Socialist societies, the Chinese leadership stresses 
that children belong to the nation, not to the family. A future goal is 
to remove socialization of offspring from the family sphere. Short of 
that, parents are urged to raise their offspring to serve the interests of 
the nation, not the family. The importance of children to Chinese 
society is stressed at their birth. "One pregnancy, one live birth; one 
live birth, one healthy child" is the slogan. 

Before 1949 the low status of young women was reflected in high in- 
fant and maternal mortality rates. 30 The women's health was poor. The 
high incidence of osteomalacia among women in North China may 
have resulted from differential eating patterns and work habits of the 
sexes; 31 as a result childbirth was dangerous. High levels of infant mor- 



34 MEDICINE AND PUBLIC HEALTH 

tality resulted from the common notion that childbirth was defiling. 
The pregnant woman was considered unclean; she could not pass 
through the neighbors' front portals for fear of offending the gods 
guarding it. 32 Childbirth took place in cowsheds and pigsties since the 
fetal blood defiled. 33 A woman in labor was commonly referred to as 
having "one foot in the grave and one foot out," and midwifery was a 
low status occupation. 

The improved position of young women in China is reflected in su- 
perior conditions of childbirth. "Old style" midwives have been re- 
trained, and activists recruited to replace those who boycott training 
classes. By 1956 it was estimated that trained health workers oversaw 60 
per cent of rural births, greatly reducing infant and maternal mortal- 
ity. 34 During the Great Leap Forward in 1958, the collective took over 
childbirth. Brigades constructed "happy nursing homes". Included in 
their services were: grain and oil subsidies brought to the women; child- 
care during delivery; pick up and return of the women from prenatal 
examinations and childbirth; recreational and political education for 
women while in the clinic. The mother was expected to leave her child 
at the children's home until it was of age for nursery school. Such at- 
tempts at collective childbirth quickly collapsed, and birth returned to 
the home in rural areas and to neighborhood clinics in urban centers. 36 

Should less expensive community social services for child care become 
available, family control over socialization of offspring could be re- 
duced. During the Great Leap, a time when women were encouraged to 
work the fields, day care centers were built in numerous rural and 
urban communes. These did not survive, due to their cost and the pau- 
city of trained women with leisure to run them. Mothers were concerned 
about the rapidity with which illness spread through the nursery, and 
the times set for fetching children conflicted with the dinner hour. De- 
spite such inconveniences, women regard such centers favorably; there, 
their children "learn many good things" that they cannot learn at 
home, such as reading, nursery rhymes, and games. If centers were 
widely available at low cost they would be utilized by rural working 
women as they are now by urban factory wives. 

Nurseries and early child care seem to be provided mainly in well-to- 
do model communes located on the outskirts of large urban centers, 
such as the Red Flag commune in the Peking suburbs. Poorer commu- 
nities organize rudimentary child-watching services during harvest and 
sowing. At other times, child care services remain limited to the private 
arrangements made by each family. Mothers call on in-laws, kinsmen, or 
neighbors to watch the children; older offspring care for the younger. 
Such child care arrangements incur obligations which the women them- 
selves must repay. Thus, child care consumes much of their time. It is 



THE ROLE OF THE FAMILY 35 

often reported that "few mothers with children have the opportunity to 
work in the fields." 37 In urban areas, child care is organized by unions 
at the factories; rudimentary services may also be set up at residential 
street committees at low cost. 

The family trains the children but families control education to a 
lesser extent than in the past. Literate parents teach their children to 
write characters before they go to school. Since illiterate parents cannot 
do this, class differences in achievement are perpetuated. Except for 
modern mechanized tasks, such as driving tractors or operating sewing 
machines, even occupational training remains in the family. The mas- 
ter-apprentice relationship based on the father-son model persisted long 
after liberation. Fathers versed in ancient skills such as herbal medicine 
would induct their sons or another young man into the family secrets. 
This information was guarded through personal relationships and was 
not disseminated through the formal educational system. During the 
Cultural Revolution the master-apprentice relationship was criticized. 
The community now collects and codifies indigenous peasant knowl- 
edge of matters ranging from weather forecasting to herbal medicines. 
Where fathers still monopolize indigenous skills as a personal posses- 
sion attempts have been made to bring the older teachers into coopera- 
tives so that occupational training can become the responsibility of the 
collective. The half-work half-study middle schools that ran from 1958 
to 1960 and agro-technical middle school courses that began during the 
Cultural Revolution train all children in the same agricultural and in- 
dustrial tasks. This has reduced occupational training down in the fam- 
ily sphere. 

The Impact of Illness, Aging and Death on Family Roles 

The numerous functions performed by the family include 
care for the ill and elderly. The performance of these tasks in the 
family means that local culture has an impact on the definition of 
health and treatment of illness. In China, as in America in the past, the 
wife cares for ill members of the family at home— primarily through 
"folk wisdom". Medical remedies and suggestions are often acquired 
from older women who are available to help when family illness occurs. 
Still a* repository of folk lore regarding the origin and cure of illness, 
the Chinese women decides who will treat the family members. 
Will the illness come under the bailiwick of the herbalist, the Chinese 
acupuncturist, the neighborhood clinic, or can she cure it herself with 
a recipe of herbal tea? The woman makes basic decisions regarding the 
health care of family members: she is not merely a mediator between 
outside expert and patient as is her Western middle-class counterpart. 38 
Care for the elderly has been largely removed from the middle-class 



36 MEDICINE AND PUBLIC HEALTH 

Western home where the "age revolution" caused by the decline in 
mortality of young adults and the concomitant extension of life and 
availability of life and burial insurance have also made death less so- 
cially visible. 39 In an underdeveloped society such as China, aging and 
death is socially present, and the burden of care for the aged falls on 
the family. In the past, Chinese parents bore numerous children, confi- 
dent that their sons would care for them in their old age. Robert Marsh 
interviewed Taiwanese of Taipei and found that the majority of older 
parents expected care from their adult offspring. 40 

In the PRC, abundant welfare or insurance is not available to sub- 
stitute for that previously provided by offspring. The collectives pro- 
vide two sorts of funds to support the elderly— welfare pensions and old- 
age homes. Urban parents depend on labor union insurance. None of 
these offers a substitute for the status provided by mutual help of the 
offspring. 

Rural welfare funds are limited. Only one per cent of the commune 
funds was invested in welfare in I960. 41 Although the amount may have 
been increased since then, only those applicants of approved political 
background, such as widows of soldiers and martyrs, qualify for sub- 
stantial support. Another kind of community social assistance was in- 
troduced in 1958 when communes built "happy homes for the aged". 
Old age homes are self-supporting; the elderly do handicraft work and 
vegetable gardening. If they have children, they might just as well help 
around their own homes, such as doing child care, instead of going to 
the old age home. In most cases people without adult sons and daugh- 
ters able to support them enter the homes. Old age homes, therefore, are 
not substitutes for the status that parents and children gain through 
caring for the older generation. Such services do have an impact on 
rural family structure, however. Widows and widowers who might oth- 
erwise have remarried to obtain personal care can now avoid it if as- 
sured community assistance. 

In urban China workers and employees are entitled to retirement in- 
surance, the amount depending on the specific regulations of the union 
located where they work. The worker's position and length of employ- 
ment are taken into account. 12 Parents supported by a worker will re- 
ceive pensions if the offspring is disabled or dies. 

The change in the frequency of death as an occurrence and in the 
population at risk of death has had an impact on family roles. The im- 
provement of health conditions has reduced the proportion of children 
who have lost one or both parents. Further, one can expect a larger pro- 
portion of families with three generations under one roof. The exten- 
sion of life means that more families have grandparents or great grand- 
parents present. 43 As a result, elderly people have become more involved 



THE ROLE OF THE FAMILY 37 

in family life. Household size may even increase somewhat. This may 
not be a marked increase despite mortality decline, however. Thomas 
Burch has shown that in contemporary developing nations where mor- 
tality has declined household size has been influenced by fertility rather 
than by vertical or lateral extension of families. 44 

The numerous roles and tasks performed by the Chinese family in 
rural areas persisted due to the lack of extrafamilial institutions to take 
them on. However, over the decades, the family has been modified. Al- 
though the larger number of tasks still performed may make it appear 
that the family has changed little, these changes can be elaborated by 
examining the shift in power and status in family relationships. 



INTERNAL ORGANIZATIONS OF THE FAMILY AND THE 
STATUS OF YOUTH AND WOMEN 

The Status of Youth in the Family 

The traditional Chinese family subordinates youth to the 
aged. The power hierarchy was manifested in the adult sons' obligation 
to contribute their income to the household. Control by parents over 
youth was also perpetuated through blind marriage. The absence of 
free choice in marriage meant that the conjugal bond between husband 
and wife was usually weak, while the relationship a man had to his 
parents was much stronger. The attempt to alter this type of family is 
consistent with the state policies regarding the subordination of the 
interests of the lineage to political and social requirements of the work 
place. 

The extent of parental control over youth can be assessed in part by 
measuring the emergence of the conjugal family with the husband/wife 
bond as the main link. This is a measure of the decline of contractual- 
ism in marriage which reflects basic changes in the family because it 
indicates that the couple itself can make such an important decision 
when they live patrilocally. Five major types of marriage can be iso- 
lated in China today. They range from the still urban-centered "free 
marriage"— in which two people meet, form a relationship, and decide 
to marry— to three other forms of arranged marriage. In one, the future 
spouses are introduced formally by the parents, but get to know each 
other and agree to the match independently before it occurs. In the last 
ten years this type has increased in prevalence, but its frequency is 
equal to the type of arranged marriage in which parents obtain the con- 
sent of the future spouses but no effort is exerted to build a relation- 
ship between the couple prior to the ceremony. Then there is the blind 



30 MEDICINE AND PUBLIC HEALTH 

marriage which is now rare. A fifth and final form of marriage is one in 
which one or both partners is a "pariah," with a political disfigurement 
on his or her record; they often settle for socially inferior mates because 
they lack bargaining power. 

The "freely" arranged marriage like that in the West predominates 
in urban centers and among cadres in rural areas, but among peasant 
families the new form of mate selection is not yet institutionalized. Ar- 
ranged marriage and blind marriage occur because the young people 
lack extensively organized heterosexual peer groups. Also, the bride 
must be able to fit into the patrilocal household on marriage. Therefore 
the personality "fit" of the couple is considered less important than 
shared similar social characteristics; these social characteristics can be 
determined by the parents as well as the youth. Gradually, similarity of 
political thoughts is becoming more important among the educated 
youth than submissiveness of the wife in the parental home. Even in 
forms of arranged marriage with prior knowledge and acceptance by 
the couple, which comprise the large proportion of rural marriage, the 
young people feel that they have had their say in mate selection. They 
know that their parents lacked the right to veto their own mates. 

Parental control has weakened over the adult offspring's family for- 
mation. However, both before and after marriage, the young men and 
women are subordinated to the demands of family life. Adult offspring 
still contribute their money and energy to maintain the families of ori- 
entation and assume responsibility for maintaining younger siblings. 
Open youth rebellion is not positively sanctioned. Sons and daughters 
feel great guilt if they seek to break from the home. Even the youth 
who does not live at home and holds a salaried job undertakes to sup- 
port his families. One result of his continued obligation to contribute 
to the famly income is that the household head makes important deci- 
sions about his future career. An elder son or daughter with numerous 
siblings may be held back from school so as to work the land or care for 
siblings. Young people contribute to their families' social mobility 
through educational achievement and nonfarming occupations. The 
power of the youth in their families of orientation is thus uneven, ex- 
tending to some areas and not to others. 

The Status of Youth in the Community 

The commune occupational structure and administrative 
system stresses political education and education for mechanization, 
elevating the status of youth in the society. Most important are the 
introduction of new youth peer groups which, as Eisenstadt hypoth- 
esized, train the youth for social roles which they cannot learn in their 
families. 45 



THE ROLE OF THE FAMILY 39 

Young men and women compete with older men for political posts in 
production teams and brigades. Literacy, knowledge of accounting 
methods, skills in simple agricultural mechanization give the youth im- 
portance in village productive life. The age of village cadres tends to be 
under thirty, although to become a higher level official one must be 
promoted through the ranks. 46 

Youth peer groups formed around the village school, the sports teams, 
and the youth "cultural clubs". Mao Tse-tung thought propaganda 
teams further organized groups of young political activists with status, 
but without pay. Many of these positions are highly valued in the com- 
munity. The peer groups do not provide a counter value system to that 
of the regime. Even the Red Guards who appeared to be rebelling 
against the society were attempting to enforce the societal political 
values, rather than oppose them. 47 Most important the peer groups pro- 
vide social support for the youth to follow the new social values of the 
collective, although their parents may want them to act otherwise. They 
are important, for instance, in providing a place where young people 
can meet future mates and avoid arranged marriage. 

In sum, parents cannot control their offspring as completely as in the 
past. Since working class boys and girls are judged independently in the 
occupational sphere on their merits, not on their parents' achievements, 
they can turn to the community for support against their elders if they 
need to. The educational system now underlines new values of serving 
the community for low pay. Serving as barefoot doctors and veterinari- 
ans is one example. In school the youth are provided with peer group 
support to enable them to oppose their parents should they be reluctant 
to let them serve the society. New attitudes cannot be inculcated suc- 
cessfully without such peer group assistance. 

The Status of Women 

Equal before the law, with an equal right to employment 
and to the same wages for the same work, the ideology of liberation of 
women has penetrated village and town and is believed by the young 
people— but the ideology masks discrepancies in reality. When these 
occur, the "service to society" ethic tends to make it difficult for women 
to pursue claims to specific compensatory treatment. In contrast to the 
Western emphasis on individualism and achievement on the basis of 
individual abilities, the Chinese focus on serving the state and sub- 
ordinating self prohibits women's organizing to advance their par- 
ticular position. 

The bases for continued relative subordination of women in the fam- 
ily and community are related to the stage of Socialist production: the 
absence of appliances and services to lighten housework, large family 



40 MEDICINE AND PUBLIC HEALTH 

size, and lagging sex-role definitions regarding the obligation to care 
for the home and family. First, factory wages are the same for equal 
jobs, but access to jobs is not random and is sex linked. In cooperative 
handicrafts and agricultural production the wage regulation "to each 
according to his ability" reduces women's pay packet below that of 
their husbands. Because of the limited support services and definition of 
child care as primarily women's responsibility, the women are tied to 
home chores. As the Myrdals (Report from a Chinese Village) de- 
scribed, the burden of village women in the home has not been alle- 
viated greatly. Because of this, it has been difficult for them to rise in 
the political hierarchy after marriage; with small children they lack the 
opportunity to continue political education and community service. 
Since heavy labor and political service to the community are the source 
of greatest community prestige and power, women as a group may be 
considered to hold lower status than men. On marriage the rural mar- 
ried women's affines often compel her to renounce non-agricultural em- 
ployment. Factory jobs and political leadership activities may be given 
up. The girls can continue to work in agriculture after marriage, where 
they remain supervised by their in-laws. All four rural working women 
respondents gave up their jobs or left normal school upon marriage. In 
contrast, only one of the many urban working women interviewed did 
so. These other urbanites remained in their factory and white-collar 
professional jobs. Other nonworking rural informants remarked that af- 
fines considered it unfitting for them as married women to serve in polit- 
ical posts where they would come into contact with young male leaders. 
The families feared that the young men "played around with girls" and 
that they would lose face before the gossip. 

Nevertheless, sex role differentiation has declined in formal organiza- 
tions. The school system and mass media emphasize that boys and girls 
are to be equal revolutionaries and workers. There is little emphasis on 
feminity or masculinity in the socialization process. Toys for boys and 
girls, where they exist, do not differ. Clothes are often identical. Occa- 
sionally, urban women enter "men's jobs" (as defined in the West), 
such as welding or working on the docks, but the majority apparently 
assume the more "feminine." nurturant roles of primary school teachers 
and nurses. 

The implications of the changes that have occurred in the status of 
women are important in assessing their health and welfare. Their im- 
proved position at liberation led to the creation of a branch of the 
Women's Association in each commune. One woman holds an official 
position in the commune revolutionary committee and in each factory 
that employs women to represent their interests. This woman's duty is 
to stress health and birth control. As the collective has gained greater 



THE ROLE OF THE FAMILY 41 

control over child rearing techniques and the level of education of 
women has improved, young mothers have begun to follow the direc- 
tives of the women's journal regarding socialization of their children. 
They have greater say over the rearing of their offspring than do their 
affines and can begin to introduce new ideas of diet and nutrition, such 
as milk for the children. When criticized by the elders, the younger ed- 
ucated women have recourse to authority because they have learned 
child training in school. 48 

P. Bart has described the changing status of women over the life cycle 
as important in understanding their position in the community. 49 The 
young woman lacked the position of the aged mother-in-law. As the 
aging woman lost her sex and reproductive roles, there was a concomi- 
tant rise in her religious interests and functions; at menopause certain 
restrictions on her behavior and activities no longer had to be observed. 
The relative status of young Chinese women will change vis-a-vis older 
women with the decline of religiosity and the traditional culture, in- 
creased education, and the shifting focus of the hierarchy of relation- 
ships in the family, from the filial bond to the youth, as reflected in 
decline of parental control over arranged marriage. 

The Family as Repository of Culture 

As a unit that fills numerous functions in China, the family 
can still be considered one of the channels to cultural change. Despite 
the introduction of formal organizations to transmit new culture and 
values, the family persists as a carrier of culture. This is so for two 
reasons. The family preserves local tradition in areas that the political 
leaders choose not to oppose, even if the traditional values contradict 
those of the broader society. Secondly, the family is a nomic structure, 
which creates meaning for its members, and in this sense, it is difficult 
to replace. 50 An example of each can be given. 

The traditional Confucian tradition opposed local folk culture at the 
same time that it coexisted with it. Not being monotheistic, Confucian- 
ism tolerated the local culture while attempting to absorb or control it. 
In the village Confucian precepts were redefined into lineage maxim- 
like rules, understandable by the common folk. 51 In the Socialist state 
folk culture is countered chiefly where it contradicts prime foci of the 
state, especially in the areas of production, but it is only weakly op- 
posed in many other areas of life. Popular concern over feng-shui and 
grave location may be opposed when it interferes with cropping plans, 
but worship is more likely to be permitted when it is carried out 
within the confines of the home. It is likely that the folk definitions of 
illness and cure have been proscribed where they are dangerous, such as 
superstitions regarding childbirth, but tolerated where they cause little 



42 MEDICINE AND PUBLIC HEALTH 

harm, such as popular views of "womb fever," as described by Marjorie 
Topley. 52 One would anticipate that the family still perpetuates folk 
views of disease and cure which coexist with acceptance of more widely 
recognized "scientific views" of the etiology of illness. 

Where the folk culture stressed social mobility it was not in opposi- 
tion to the industrial state. Folk religion justified striving for wealth 
and achievement in the social order, and theories of feng-shai rational- 
ized failure to achieve. Through the early 1960s individualistic achieve- 
ment-orientation was consistent with Socialist ideology. McClelland's 
analysis of primary-school primers of the mid-1950s, and John Lewis' 
study of cadre training manuals in that period both concluded that the 
Chinese educational system rewarded high achievement motivation. 53 
The achievement goals stressed in the family were consistent with those 
of the formal organizational structure until these organizational goals 
were changed in the mid-1960s to stress collective rather than achieve- 
ment orientation. 

The family culture was consonant with the broader folk emphasis of 
achievement. The meaning of the individual's life was related to the 
unity of the entire family unit. The family was based on the filial bond, 
and the young person's identity was related to his or her ability to suc- 
ceed in its name. Parents defined "health" and wellbeing of family 
members in these terms. The adolescent search for identity was not a 
recognized stage of maturation. Thus, youth subordinated their per- 
sonal desires to those of the family, frequently suffering mental strain 
which was not recognized or validated by the culture. The effectiveness 
of the internalization of family and societal values to achieve was docu- 
mented by a psychiatrist who tested fifteen Shanghainese and Cantonese 
middle school students with T.A.T.s in 1961. 54 He interviewed them re- 
garding their occupational goals: "To achieve a vocation as a scientist 
or specialized worker" many replied. Did they have any worries? 
"None." But they demonstrated signs of nail biting and facial tics, and 
the dreams which were reported reflected anxiety about success in their 
studies and vocation. 

The subordination of the youth to the family unit continued 
through the mid-1960s. In the last few years as "service to the people" 
has been placed ahead of individual achievement, the young people 
would no longer find continuity between family culture and the values 
and norms of the wider society. Subordination to the culture of the 
community and state is to supersede that to the family. As youth are 
more and more highly educated, the impact of the family as the unit 
which provides meaning to their lives should be reduced. 



THE ROLE OF THE FAMILY 43 

The Patient-Practitioner Relationship and the Role of the 
Family 

The central role played by the family in the lives of its 
members makes it a critical element in the patient-practitioner relation- 
ship. Talcott Parsons has described the doctor-patient relationship as a 
therapeutic, one-to-one relationship in which the patient is a deviant, 
to be socialized back into good health. 55 Although it may be applicable 
to developed societies, this model does not fit China's developing en- 
vironment in which the doctor-patient relationship is not isolated from 
the community context which includes kinship. Wilson has suggested 
the term "community-as-patient," a concept which makes the commu- 
nity a key factor in both generating illness, and curing it. 56 

The Community as Patient 

In China's rural and urban neighborhoods, treatment of 
disease does not necessarily or primarily result from a patient's seeking 
out the doctor and willingly undergoing treatment in his hands. The 
locale's definition of the illnesses requiring care may well differ from 
that given priority by the government medical service. The latter's role 
frequently includes demonstrating to the citizens the need to take 
action against diseases having low salience in the community. There- 
fore, the community is necessarily involved in disease prevention and 
cure. 

Early on, the PRC. attempted to reduce infectious and contagious 
diseases by organizing residents to locate the carriers of diseases. In at- 
tempting to eliminate syphilis, medical practitioners trained local opin- 
ion leaders to convince the residents to report symptoms of which fam- 
ilies were ashamed. 57 Ultimately, kinsmen brought their relatives in for 
treatment. Community cooperation and organization were essential for 
detection and cure on a large scale, and, in fact, eliminated syphilis as a 
major contagious disease. 

The current government priority to improve the people's health fo- 
cuses on the prevention of debilitating diseases, in particular parasitic 
diseases. Prevention requires teaching the community methods of han- 
dling lifestock, especially sheep, storing fertilizer, and hygiene in regard 
to food preparation and dress. Families can become obstacles to health 
improvement, preferring less troublesome methods of collecting night- 
soil or planting rice seedlings than those suggested by agronomists with 
a health orientation. It is necessary to train the families in preventative 
health care, educating them in updated agricultural methods. 

Success of cure also rests on the ability of health workers to alter the 
local definitions of disease. Since some local perceptions of illness in- 
clude magical and religious causes, the healing process involves folk 



44 MEDICINE AND PUBLIC HEALTH 

doctors and religious figures to excoriate disease. One common method of 
countering the folk definition of health has been Party-led family and 
community discussions on the inefficacy of "witch-doctors.'" At the same 
time pharmacologists absorb useful elements of the indigenous medical 
cornucopia. Medical workers thereby enter directly into village and cul- 
tural life, treating the community— as well as the individual members— 
as patient. 

The Community as Practitioner 

A specialized number of community figures are primarily 
responsible for health action in the village, but the number of doctors 
remains sparse. In part a product of the low level of economic develop- 
ment and paucity of medical services, but also resulting from the social 
structure, medical workers have become social healers in a broad sense, 
and the community itself is involved in providing lay medical care. 

The figure of the healer is prestigious in any society, and he draws 
his charisma from being an agent of social control. In a Socialist society 
the doctor is prevented from using his authority to implement his own 
values if they vary from those of the body politic. In China he is viewed 
as a political figure who is responsible for change in social values and 
especially those related to health behavior. The physician is no longer a 
professional, who sets and enforces the standards of his work, but he has 
become a civil servant, who owes his position to the government and 
community. This can be seen in the implementation of the slogan 
"serve the people" and in the doctor's dual role as medical and political 
healer. 

As part of the anti-professional move in medicine, the doctor is to be 
voluntaristic, to be dedicated and a member of the elect, acting beyond 
the call of duty as a routine part of his work. As Schatzman suggested, 
voluntarism can be combined with professional practice; however, it is 
not usually taught in the West because it counters hospital efficiency 
and routine.' 8 The voluntarism expected of Chinese medical workers is 
related to the low level of health services, which impels each trained 
medical worker to perform many activities but it is also an attempt by 
the community to set the goals for the professionals. Consequently the 
village medical worker, and to a certain extent the hospital-based physi- 
cian, treats the patient as a total person. Health care adopts attributes 
of a family relationship. The model medical worker in the press is one 
who stays up nights to treat the sick, even performing the patient's 
housework while caring for him. Called upon to help one member of 
the family, the doctor frequently treats the rest of the household as well. 
The caring posture means that the doctor is viewed by the community 
as acting in its interests. The medical workers become political figures, 



THE ROLE OF THE FAMILY 45 

frequently advocating social change. For one example, the barefoot doc- 
tor promotes birth control, bringing up the topic whether or not it has 
been requested by the patient. 

The community is involved in the selection of medical workers, cur- 
tailing the power of the profession to determine its membership and 
diminishing the role of the family in placing its members in presti- 
gious occupations. Until recently, one's family background influenced 
access to professional jobs. Political leadership positions and a high 
level of education of a household facilitated attainment of higher edu- 
cation including medical training for the children. Through the 1960s 
doctors came from families of intellectuals, professionals, or cadres, who 
had the ability to socialize their offspring to pass competitive entrance 
examinations or who had personal connections to ensure entry. After 
the Cultural Revolution, revised procedures for admission to medical 
college required in-service training and the approval of the commu- 
nity. 59 Political leaders have gained greater control over the type of peo- 
ple who become medical personnel and the standards of the vocation, 
reducing the role of the professionals and of their families in perpetuat- 
ing their social position. Stratification according to social position has 
been reduced somewhat, but that by sex and age continues. Where com- 
munity and family stereotypes of medical workers coincide, they are re- 
tained. Specialists are likely to be male, whereas volunteer, paramedical 
personnel are somewhat more likely to be female, a continuation of 
their nurturing role in the family. 

Having gained leverage over the practice and training of specialized 
medical workers, the community also practices lay care. This is one 
method by which health workers can be increased in numbers. Free 
clinics in Western urban centers maintain that the majority of the com- 
munity residents can be trained to treat most of their common com- 
plaints, 60 many neighborhood clinics taking a leaf from the Chinese 
practice of training residents which appears to be consistent with this 
view. Further, in underdeveloped countries with limited resources for 
care and cure, the most reasonable method of ensuring good medical 
treatment is to focus on the illnesses that have the probability of affect- 
ing the majority. This goal can better be achieved if the residents enter 
into the system of medical treatment themselves. The family volunteers 
its services in medical care. Unpaid housewives have organized urban 
neighborhood clinics, and some are trained in record-taking, freeing 
others for specialized skills. Some housewives have even been trained to 
detect common complaints, such as infection of the middle ear and mea- 
sles. 61 Rural medical workers are drawn from local families. As "bare- 
foot doctors" they continue productive labor in the fields, retaining 
their "lay connections" with local families. 62 Even in China, however, 



46 MEDICINE AND PUBLIC HEALTH 

the political impact of giving the local residents greater control over 
their own medical services may be limited. Apart from the short-term 
intensive hygiene campaigns, most clinics have apparently not estab- 
lished mechanisms for involving patients in their own medical care 
other than by their becoming workers in the clinic. The trend of pa- 
tient-practitioner relationship in China, nevertheless, remains that of 
reducing the role the family plays as an isolated unit and increasing 
that of the community in medical behavior. 

Conclusion 

The concept of the transitional society has been introduced 
to explain the economic context in which rural families perform nu- 
merous roles and activities. Extra-familial organizations have not been 
sufficient to replace family economic, political, educational and welfare 
functions. Nevertheless, the family has been brought into closer relation- 
ship with the community than before liberation. The ways that the 
family relates to the community have also changed somewhat over the 
past two decades. At present the important role of the family in the 
community and in the lives of its members suggests that family behavior 
figures in the etiology of disease and in health care. Further research 
and observation of the family in the Chinese setting, with an eye to 
discovering its relation to health behavior, should prove fruitful. 



THE ROLE OF THE FAMILY 47 

REFERENCES 

1. Margaret Read, Culture, Health and Disease (London: Tavistock Publications, 
1966), pp. 9-14, 52-69, and passim-. A more systematic but limited discussion 
is in Alfred H. Katz, "The Social Causes of Disease," in Hans Peter Dreitzel. 
ed., The Social Organization of Health (New York; The Macmillan Co., 1971). 
pp. 5-14. Katz diagrammed the impact of social living as a preclinical factor of 
illness as follows: 

Independent Variable Intervening Variable Dependent Variable 

Physical and social stress Life style (Including Illness or pathology 

family support) 

2. R. D. Laing's work on family communication patterns documents them as 
figuring in the etiology of mental illness. Laing and Esterson, Sanity, Madness and 
the Family (London: Tavistock, 1964). 

Research on correlates of physical illness suggest that the absence of family 
ties and friendship networks are associated with the incidence of clinical 
tuberculosis. Thomas A. Holmes, "Multidiscipline Studies in Tuberculosis," in 
Sparer, ed., Personality, Stress and Tuberculosis (New York: International Uni- 
versities Press, 1956), pp. 376-412. 

3. Sociologists of health behavior currently focus on two issues regarding dif- 
ferential rates of illness by social class: How the "culture of poverty" renders 
the poor apathetic and unable to perceive and treat their illnesses, and the 
extent to which differential disease rates can be explained not by the "culture 
of poverty" but by medical institutions which do not enter the ghettoes, and 
welfare services which are reluctant to pay for superior medical treatment for 
the poor. These two explanations are not mutually contradictory. For the latter 
viewpoint see Rodger Hurley, "The Health Crisis of the Poor," in Dreitzel, ed., 
pp. 83-122. 

4. Edward A. Suchman, "Ethnic and Social Factors in Medical Care Orientation." 
"Social Patterns of Illness and Medical Care," "Social Factors in Illness Behavior." 
in Milbank Memorial Fund Quarterly 47.1:69-93, pt. 2 (January 1969). Suchman 
found definite socio-ethnic differences in the perception of illness, holding the 
incidence of disease constant. The invisibility of poverty and its social con- 
sequences were discussed in Michael Harrington, The Other America (New 
York: Macmillan, 1963). 

5. See the special issue on community medical care, Milbank Memorial Fund 
Quarterly 46.3, pt. 1 (July 1968), describing the funding and organization of 
the Montefiore medical clinic in New York City under the auspices of O.E.O. 

6. L. B. Schorr, J. T. English, "Background, Context and Significant Issues in 
Neighborhood Health Center Programs," in ibid., pp. 289-96. 

7. Reviewed in Janet Salaff, "Social Mobilization and Public Health in China and 
the United States," unpublished manuscript, 1965. 

8. Suggested by H. R. Stub, "Family Structure and the Social Consequences of 
Death," in Jeanette R. Folta, Edith S. Deck, eds., A Sociological Framework for 
Patient Care (New York: John Wiley & Sons, 1966), p. 194. 

9. Personal communication to Knutson, cited in Andie L. Knutson, The Individual, 
Society and Health Behavior (New York: Russell Sage Foundation, 1965), p. 275. 

10. Robert R. Sears, Eleanor E. Maccoby, and Harry Levin, Patterns of Child Rear- 
ing (Evanston: Row, Peterson and Co., 1957). 

11. D. E. B. Jeliffe and F. J. Bennett, "Indigenous Medical Systems and Child 



48 MEDICINE AND PUBLIC HEALTH 

Health," Journal of Pediatrics 42:248-58 (July 1957). Read found this kind of 
threefold classification prevalent in cultures of Africa, Asia and Latin America: 
Read, pp. 24-37. 

12. Marjorie Topley, "Chinese Traditional Ideas and the Treatment of Disease: 
Two Examples from Hong Kong," Man 5.3:421-37 (September 1970). Topley 
found that some illnesses such as measles had an indigenous metaphysical 
explanation. Parents were likely to seek cures for their offspring in different 
medical traditions. Folk systems of medicine coexisted with acts, prescriptions 
and attitudes regarding Western scientific therapy. This coexistance of different 
medical traditions has also been documented for Mexican communities; Horacio 
Fabrega, Jr., "Dynamics of Medical Practice in a Folk Community," Milbank 
Memorial Fund Quarterly 48.4:391-412, pt. 1 (October 1970). 

13. C. K. Yang, The Chinese Family in Communist Transition, (Cambridge: M.I.T. 
Press, 1959); Janet Salaff, "Youth, Family and Political Power in Communist 
China," Ph.D. dissertation. University of California, Berkeley, 1972. Chen Pi- 
chao drew on press publications to describe the birth control campaigns in 
China," China's Birth Control Action Programme, 1956-1964," Population Studies 
26.2:141-58. 

14. John Aird listed six major efforts at collecting demographic data in China since 
1949. These were, in chronological order: (1) the land reform population 
investigations which began prior to 1949 and ended in 1953; (2) urban popula- 
tion registers set up in major cities from 1949 to 1953; (3) experimental vital 
registration carried out by the Ministry of Health between 1950 and 1954; (4) 
the national population census taken during 1953 and 1954; (5) the rural 
population registers set up during 1954-1956; (6) a "field count of some kind" 
undertaken during the summer of 1964 by the Ministry of Public Security: 
Aird, "Population Growth and Distribution in Mainland China," in Joint 
Economic Committee of the U.S. Congress, An Economic Profile of Mainland 
China (New York: Frederick A. Praeger, 1968), pp. 344-52. 

15. Salaff, "Social Mobilization and Public Health in Communist China," and 
"Youth, Family, and Political Power in Communist China," chapter II. 

16. The responses of 101 respondents were tabulated for the Ph.D. thesis from 
which this paper is drawn (ibid.). There were sixty-five males and thirty-six 
females; sixty were ever married, and forty-one never married. They were fairly 
evenly distributed by age from age eighteen to over forty. 

17. Some of these studies were summarized in Michel Oksenberg, "Sources and 
Methodological Problems in the Study of Contemporary China," in A. Doak 
Barnett, ed., Chinese Communist Politics in Action (Seattle: University of 
Washington Press, 1969), pp. 577-606. 

18. Jack Potter, "From Peasant to Rural Proletariat," in Jack Potter, et a!., eds., 
Peasant Society: A Reader (Boston: Little Brown: 1967), pp. 407-19. 

19. This range of income distribution is given in E. W. Wheelwright and Bruce 
McFarlane, The Chinese Road to Socialism (New York: The Monthly Review 
Press, 1970), pp. 193-4. 

20. For a description of the family meetings in an earlier period see the auto 
biography of a Communist leader's family at the turn of this century; Agnes 
Smedley, The Great Road: The Life and Times of Chu Teh (New York: 
Monthly Review Press, 1956). This same kind of discussion is common in the 
village studied by the Myrdals in 1963 and 1967, Report from a Chinese Village 
(New York: Pantheon, 1965), passim. 

21. "Family Criticism and Repudiation is Fine," Wen hui-pao (Shanghai), December 



THE ROLE OF THE FAMILY 49 

15, 1967, on Shanghai Radio, December 14, 1967. A collection of articles from 
the Chinese press and radio broadcasts concerning family study can be found 
in, "Rural Family Mao Tse-tung Thought Study Classes," Union Research 
Institute, (Hong Kong) 54.8 (January 29, 1969). 

22. Tsao Hsin-hua, "Using Materialist Dialectis to Revolutionize the Family," 
Peking Review no. 47:10-12 (November 20, 1970). 

23. H. Kent Geiger, The Family in Soviet Russia (Cambridge: Harvard University 
Press, 1968). 

24. "Family Criticism and Repudiation is Fine," op. cit. 

25. The laws regarding inheritance of social class designation can be found in 
Chinese Central Government Administrative Council, "Kuan-yu hua-fen nung 
ts'un chieh-chi ch'eng-fen ti chueh-ting," (Decision on the demarcation of 
rural class status), Political Report of the 44th Session of the Administrative 
Council, August 4, 1950, Hsin-hua yueh-pao. (New China Monthly) 2.5:973-981. 
A discussion of class standing emerged from the debates regarding the relation- 
ship between attitudes and behavior by social strata in the Cultural Revolution, 
"Collection of Material on Reversal of Verdicts," U.S. Consulate General (Hong 
Kong), Survey of China Mainland Magazines, no. 617. 

26. Sun Y n-chieh, "One's Own Manifestations is the Important Thing." China 
Youth, February 16, 1966; "To Understand the Family Correctly is the Starting 
Point in Striving for Progress," China Youth, March 16, 1964, translated in 
Survey of China Mainland Magazines, no. 415:38-40. 

27. James Bossard and Eleanor Boll, The Large Family System (Philadelphia: Uni- 
versity of Pennsylvania Press, 1956). 

28. "Hu-pei sheng 22,251 ch'eng-hsiang fu-nu yueh-ching chi sheng-yu ch'ing-kuang 
t'iao-ch'a fen-hsi" (Investigation and analysis of the childbirth and menstrua- 
tion conditions of 22,251 rural and urban Hupei women), Chung-hua fu-ch'an- 
k'otsa-chih (Chinese Journal of Obstetrics and Gynecology) 8:5-11 (1960). 

29. I have come to this conclusion in Salaff, "Institutionalized Motivation for 
Fertility Limitation in China," in a forthcoming issue of Population Studies. 

30. Irene B. Taeuber, "The Families of Chinese Farmers," in Maurice Freedman 
ed., Kinship in Chinese Society (Stanford: Stanford University Press, 1970), p. 
71. Taeuber reanalyzed data on demographic processes from John L. Buck's 
1930-1931 survey in China; she found crude death rates of 23.1 for all regions 
infant mortality rates of 156 per 1,000 live births. Maternal mortality rates may 
have been as high as 150 per 10,000 live births during war years, and 100-130 
in urban centers in 1940; "The Effects of War on Health," Chinese Medical 
Journal 71.5:321-58 (September 1953); Lim Kahti (Department of Obstetrics and 
Gynecology, Peking Union Hospital), "Obstetrics and Gynecology in the Past 
Ten Years," Chinese Medical Journal 79.5:375-83 (November 1959). 

31. Read, pp. 13-14. Most cases of this disease, which is caused by lack of sunshine 
or a dietary deficiency of Vitamin D, occur in parts of the world where sunshine 
is abundant, and result from regulations enforcing female seclusion. I do not 
know whether such restrictions were found in areas of North China where the 
highest rates of osteomalacia were documented. 

32. Francis L. K. Hsu, Under the Ancestor's Shadow (Doubleday: 1967), p. 204. 

33. Wei Lin-fu, "Hsueh-hao hsin chieh-sheng-fa wei chung-chung fu-wu ti fu-nu-hui 
chu jen yen lien-hua" (Study well the way that Women's Association Chair- 
woman Yen Lien-hua serves the masses with the new method of midwivery). 
Che-kiang jih-pao, March 23, 1952. 

34. Lim Kahti, op. cit. 



50 MEDICINE AND PUBLIC HEALTH 

35. "P'ing-nan nung-ts'un fu-ch'an-yuan chu kuang ch'eng-ch'an," (Childbirth gar- 
dens in P'ing-nan village are flourishing), Kuang-hsi jih-pao, November 18, 1959: 
"Mu-tzu k'ang fu-lo-yuan hao-ch'u to," (Happy nursing homes have manv 
advantages), Chung-kuo ch'ing-nien-pao, (China youth paper). 

36. By 1957 the proportion of women giving birth assisted by trained health work- 
ers had risen to 61.1% in rural areas and 95% in large cities. In Shanghai in 
1957 23.9% of the women gave birth in hospitals, 62.1%, in health stations, and 
7.9% assisted by midwives at home. Lim Kahti, op. cit. 

37. Myrdal and Myrdal, p. 239. 

38. Robert R. Bell, "Impact of Illness on Family Roles," in Folta and Deck, p. 179. 

39. Holger R. Stub, "Family Structure and the Social Consequences of Death." in 
Folta and Deck, p. 192. 

40. Robert M. Marsh, "The Taiwanese of Taipei: Some Major Aspects of their 
Social Structure and Attitudes," Journal of Asian Studies 27.3:571-84 (May 1968). 

41. Chin Ming, "The Way in Which Financial Work in People's Communes Serves 
Distribution," Hung-ch'i (Red Flag), no. 22 (November 16, 1960), p. 38. 

42. Joyce K. Kallgren, "Social Welfare and China's Industrial Workers," in A. Doak 
Barnett, p. 553. 

43. Stub, p. 195. 

44. Thomas Burch, "The Size and Structure of Families: A Comparative Analysis 
of Census Data," American Sociological Review 32.3:347-363 (June 1967): and 
"Some Demographic Determinants of Average Household Size: An Analytic 
Approach," Demography 7.1: 61-69 (February 1970). 

45. Sergei Eisenstadt, From Generation to Generation (Glencoe: The Free Press, 
1956), pp. 237-38. 

46. Michel Oksenberg, "Local Leaders in Rural China, 1962-1965: Individual At- 
tributes, Bureaucratic Positions and Political Recruitment," in A Doak Barnett. 
pp. 155-215. 

47. Richard and Amy Wilson, "The Red Guards and the World Student Movement," 
The China Quarterly, no. 42:88-104 (April-June 1970). 

48. Foong Wong, "A Chinese Family in Singapore," in Barbara E. Ward, ed., 
Women in the New Asia (New York: UNESCO, 1963), pp. 417-8. 

49. Pauline B. Bart, "Why Women's Status Changes in Middle Age," paper presented 
at the meetings of the American Sociological Association, San Francisco, 1969. 

50. Peter Berger and Hansfried Kellner, "Marriage and the Construction of Reality." 
in Hans Dreitzel, ed., Recent Sociology, 2 (New York: Macmillan, 1970), pp. 49-72. 

51. Liu Hui-chen Wang," An Analysis of the Chinese Clan Rules: Confucian Theories 
in Action," in David S. Nivison and Arthur F. Wright, eds., Confucianism in 
Action (Stanford: Stanford LIniversity Press, 1959), pp. 63-96. 

52. See Topley. 

53. David McClelland, "Motivational Patterns in Southeast Asia with Special 
Reference to the Chinese Case," Journal of Social Issues 19.1:6-19 (1963): John 
W. Lewis, "Party Cadres in Communist China," in James S. Coleman, ed., 
Education and Political Development (Princeton: Princeton University Press, 
1965), pp. 435-6. 

54. Denis Lazure, "The Family and Youth in New China: Psychiatric Observations." 
Canadian Medical Association Journal 86:179-82 (January 27, 1962). 

55. Talcott Parsons, The Social System (Glencoe: The Free Press, 1951), pp. 428-73. 

56. Robert N. Wilson, The Sociology of Health: An Introduction (New York: 
Random House, 1970), p. 59. 

57. Joshua S. Horn, Away With All Pests: An English Surgeon in People's China: 



THE ROLE OF THE FAMILY 51 

1954-1969 (New York: The Monthly Review Press, 1969), pp. ,89-93; Edgar 
Snow, The Other Side of the River (New York Random House, 1962), pp. 276-81. 

58. Leonard Schatzman, "Voluntarism and Professional Practice in the Health 
Professions," in Folta and Deck, pp. 145-55. 

59. NCNA, November 9, 1967, details the changes wrought to medical education 
in Shantung Medical College; see also "The 'Revolution' in Medicine,'' Jen-min 
jih-pao, August 24, 1968. 

60. Constance Bloomfield, and Howard Levy, "Underground Medicine: Ups and 
Downs of the Free Clinics," Ramparts no. 3:35-42 (March 1972). 

61. "Many New Things Emerge in Kiangsi Struggle," NCNA, January 12, 1969. 
describes a Nanchang street clinic set up by residential housewives during the 
Cultural Revolution. 

62. "The Orientation of the Revolution in Medical Education As Seen from the 
Growth in Numbers of Barefoot Doctors," Wen hui pao (Shanghai), September 
4, 1968, in Shanghai Radio, September 3, 1968; "Investigation Report [on the 
barefoot doctors]," Hung-ch'i (September 1968). 



SURGERY PAST AND PRESENT 



John Z. Bowers, M.D. 



China was the last major country to accept western principles 
and practices of surgery. The absence of surgery was based in part on 
the enduring historic Chinese tradition that the human body is a 
sacred treasure which must not be marred— as by a surgical incision. 
The liver and heart were held to be most precious and a Chinese 
lover embracing his sweetheart would whisper as terms of endearment, 
"My heart and my liver" (Wallnofer and von Rottauscher 1965, p. 77) . 

Reverence for the human body is an essential root of the Chinese cul- 
ture, dating from the dawn of Chinese civilization. It also relates in 
part to Confucian doctrine, the practice of ancestor worship and filial 
piety. 

Therefore, the Chinese traditional system of medicine, Chung-i, did 
not include surgery in its therapeutic armamentarium— which was 
based on acupuncture, moxibustion, and an enormous materia medica. 

None of the ancient medical treatises with their voluminous chapters 
on internal medicine include significant discussions of surgery. The 
classic text of Chinese medicine, Huang Ti Nei Ching Su Wen (Yellow 
Emperor's Textbook of Internal Medicine), published in the late Chou 
or early Han dynasty, mentions surgery only as a last resort or in the 
curettement of ulcers. Geographic and cultural isolation also kept 
China aloof from surgical progress in Europe. 

A set of Chinese "surgical" instruments in the collection of the late 
Dr. Eugene Opie includes delicate lances, forceps, and probes, which 
could only be used for the most superficial procedures. Although all 
practitioners were accorded low social rank, the level of the surgeon was 
comparable to that of a beggar or prostitute and was inferior to that of 
the medieval barber-surgeons of Europe. 

There are a few references to surgeons and surgery in the early his- 

53 



54 MEDICINE AND PUBLIC HEALTH 

tory of medicine in China. Pien Ch'iao, who practiced in the second 
century B.C., is said to have used anesthetic agents and to have per- 
formed cardiac transplants in living patients. Hua Tu (Hua Yuan-hua, 
also Hua T'o), who lived at the end of the Han dynasty (115-205 A. 
D.), is described as an early practitioner of surgery. From a formula 
that he may have obtained from two hermits hidden in a mountain 
cave, Hua Tu prepared an anesthetic mixture, Ma Fu Shuan ("Ma," 
hemp or narcotic; "Fu," aromatic; and "Shuan," powder), which he ad- 
ministered as an anesthetic with wine. (It was probably Indian Hemp.) 
When the patient became drunk and unconscious, Hua Tu is reported 
to have performed laparotomy for various gastric intestinal disorders 
and other surgery. One of his patients complained of intense abdominal 
pain accompanied by loss of eyebrows and whiskers. Hua Tu made a 
diagnosis of necrosis of the spleen, performed a partial splenectomy, 
and the patient recovered in 100 days. 

Hua Tu's most renowned patient was General Kwan who developed 
osteomyelitis of the humerus after being wounded by an arrow. After 
administering Ma Fu Shuan, Hua Tu had the half-drunken general 
play chess with one of his adjutants while Hua scraped the necrotic 
bone. Hua Tu is said to have died in prison and all of his manuscripts 
were destroyed before his death. Datura, Rhododendron Sinense, and 
Jasmine Simbac were used by other surgeons for anesthesia. 

Ma Shi-Huang is cited in legend as a veterinary surgeon who treated 
ponies and dragons. Ma was so popular with his "dragon clientele" that 
they kidnapped him and he disappeared from medical history. 

Another surgeon, Yu Fu, according to legend, "opened the abdomen, 
washed the stomach and cleansed the intestines" (Liang, 1934, p. 2). 
But these fragments of medical history were largely legendary. 

Dr. Gillan, who accompanied Lord Macartney's mission to China, 
1793-94, reported that surgery did not "exist" in China. Instead he 
found that the Chinese excelled in "cutting of corns and nails;" in 
cleansing the ears; in applying medicinal plasters. 

Castration was the only accepted surgical procedure. Originally a 
form of punishment, it was later performed to prepare servants for the 
Imperial courts. The penis, scrotum, and testes were amputated with one 
sweep of a sickle-shaped knife and the eunuchs appointed to the court 
were inspected twice a year by the representatives of the emperor to as- 
sure that there had been no regeneration. 

The development of Western surgery in China goes back to Dr. Peter 
Parker, a graduate of Yale Medical School, who came to China as a 
medical missionary. On November 9, 1835, Parker opened the Canton 
Ophthalmic Hospital at 7 Green Pea Street, Canton, famed with sailors 
around the world as "Hog Alley," for its saloons and brothels. Parker 



SURGERY PAST AND PRESENT 55 

operated on hundreds of cases of cataract that flocked to his hospital. 
Parker's speed as a surgeon was remarkable; he is reported to have re- 
moved a pendulous sarcoma of the lips three feet in length and two feet 
across in twelve seconds. He was the first surgeon in China to use sulfu- 
ric ether as an anesthetic and the first to perform mastectomy. 

Other missionary surgeons who followed Parker expressed their sur- 
prise and pleasure at the number of patients who came to them for 
medical and surgical care. However, if a part of the body were removed, 
it was given to the patient or his family so that it could be placed in his 
coffin at the time of death. 

It was not until November 22, 1913, that an official edict granted per- 
mission for autopsies. This favorable turn was occasioned by a devastat- 
ing epidemic of pneumonic plague in Manchuria in which 60,000 per- 
sons died. Half of the practitioners of Chinese traditional medicine, 
who had no understanding of the communicability of the disease, died 
from the plague. On the other hand, only 2 per cent of the practitioners 
trained in Western medicine and who understood communicability suc- 
cumbed. 

Peking Union Medical College and Training in Surgery 

The first program in academic surgery in China was estab- 
lished at the Peking Union Medical College (PUMC) , founded and 
supported by The Rockefeller Foundation through its China Medical 
Board (CMB) . 

The problems of medicine and health in China had been an early 
interest of Mr. John D. Rockefeller, inspired in part by his principal 
advisor on philanthropy, Reverend Frederick T. Gates. In 1909, at 
Gates' suggestion, Mr. Rockefeller financed the Oriental Educational 
Commission to evaluate educational, social, and religious conditions in 
the Far East. The members of the commission were Ernest De Witt 
Burton and Thomas Crowder Chamberlin, professors of theology at the 
University of Chicago. They reported that there were less than 400 stu- 
dents studying Western medicine in China— one medical student for each 
million people. The leading medical school at that time and prior to 
establishment of PUMC was the Union Medical College in Peking sup 
ported by three British and three American missionary societies. Based 
on their report, Gates judged that the time was not propitious for a 
university development program in China because of insistence on gov- 
ernmental control and anti-foreignism. 

With the establishment of The Rockefeller Foundation in the spring 
of 1913, Gates pressed for a program in medical education in China. One 
of his principal supporters was Charles W. Eliot, president emeritus of 
Harvard who in 1912 had studied problems in China on a mission for 



56 MEDICINE AND PUBLIC HEALTH 

the Carnegie Endowment for International Peace. Eliot considered that 
the introduction of objective, inductive reasoning was essential to the 
advancement of China from her medieval state. He also decided that 
"There is no better subject than medicine in which to teach the univer- 
sal inductive method" (Eliot 1914, p. 2). 

The First China Medical Commission (H. P. Judson of the Univer- 
sity of Chicago, Francis W. Peabody of Harvard, and Roger S. Greene, 
U.S. Consul in China), sponsored by The Rockefeller Foundation, 
spent part of the spring and summer of 1914, four months in all, in 
China. They described tuberculosis, hookworm, and syphilis as the 
most widespread diseases; medical care was abysmal. Essentially all of 
the nurses were men. 

The commission's leading recommendation was that The Rockefeller 
Foundation should undertake a program in medical education in 
China based at the Union Medical College in Peking. In June, 1915, 
the CMB purchased the Union Medical College. 

A Second China Medical Commission led by Wallace Buttrick, direc- 
tor of the CMB, with Simon Flexner and William H. Welch, visited 
China in the fall of 1915. Their principal recommendation was that the 
college should develop a standard equal to the best in the West; that 
teaching should be in English; and that the school should develop its 
own premedical program. 

The premedical school opened in September, 1917, and the first medi- 
cal students were enrolled in the fall of 1919. Three-quarters of the orig- 
inal faculty were from the United States. 

The first head of surgery was Adrian Taylor, a graduate of the Uni- 
versity of Virginia in 1905. After serving for ten years as a Southern 
Baptist missionary at Yangchow, Taylor was awarded a postgraduate 
fellowship by the CMB for study at Harvard. Taylor then completed 
the surgical residency program at Hopkins under William Steward 
Halsted and returned to Peking in 1920. He was joined by Jerome P. 
Webster, who assumed responsibility for developing a surgical residency 
modeled on the Hopkins program. The first assistant residents, three in 
number, entered the program in 1927. 

Another early member of the department, Frank L. Meleney, M.D., 
from Columbia University College of Physicians and Surgeons, began 
his studies on surgical bacteriology at PUMC. 

A Chinese associate in the Department of Surgery, J. Heng Liu, a 
graduate of Harvard, was the first Minister of Health for the National- 
ist Government. 

In addition to general surgery there were residency programs in 
ophthalmology; ear, nose, and throat; and orthopedics. 

The most illustrious patient to enter the surgical service at PUMC 



SURGERY PAST AND PRESENT 57 

was Dr. Sun Yat-sen. He came up to Peking in 1925, a dying man, and 
after the ministrations of native practitioners were ineffective, was ad- 
mitted to PUMC. His family most reluctantly agreed to surgery and a 
laparotomy and biopsy revealed carcinomatosis originating in the liver. 
He died at home soon after the operation. With even greater reluctance 
his family agreed to an inspection of the abdomen, post-mortem, and a 
sliver of the tumor was removed to verify the diagnosis. The funeral 
service was held in the auditorium of PUMC and the hearse was the 
PUMC van draped in black. 

Years later the Japanese tried to precipitate a crisis in Sino-American 
relations by claiming that the pathologists at PUMC had broken their 
agreement with Sun Yat-sen's family and removed abdominal viscera. A 
careful inspection of the pathology department was fruitless but to "save 
face" the Japanese staged a mock ceremony with a funeral urn claimed 
to contain the organs that had been "stolen" by PUMC. 

Surgery Today 

The Chinese place great emphasis on their accomplishments 
in restorative surgery, especially in the reattachment of extremities that 
have been amputed by trauma. We suspect that this goes back in part 
to their historic reverence for an intact human body. 

The first reattachment that received world-wide attention occurred 
on January 2, 1963, when a factory worker in Shanghai severed his 
right hand above the wrist. The operation required seven hours and the 
post-operative care included hourly temperature readings with an elec- 
tric skin thermometer. Three years later he was visited by a British sur- 
geon (J. S. Horn) and found to have only a slight limitation in wrist 
movements and the skin was not quite as sensitive as on the other 
hand— but he had become a first-rate ping-pong player! 

This successful operation stimulated the training of teams in the 
major industrial centers to perform similar procedures. Special stainless 
steel surgical needles, synthetic fibers of small diameter with great ten- 
sile strength and operating microscopes were fabricated for use by these 
teams. 

By holding the amputated part at a temperature just above freezing 
the American dictum of a six-hour maximum interval between the in- 
jury and restorative surgery has been significantly prolonged. Special at- 
tention is paid to venous anastamosis; it is usually advisable to shorten 
the bone to prevent tension on the suture line. 

The successful removal of enormous ovarian cysts previously consid- 
ered inoperable is a major claim for the "new surgery" in China. The 
popular atlas Medical Workers Serving the People Wholeheartedly 
(1971) features a dramatic sequence of more than twenty pictures of 



58 MEDICINE AND PUBLIC HEALTH 

the successful removal of an abdominal tumor (ovarian cyst) weighing 
90 jin (45 kgs.). Before surgery "she could not walk or lie down, but 
knelt on the bed day and night." The Chinese doctors determined that 
the tumor was not malignant. Special anesthetic apparatus was fabri- 
cated. The operation required twelve hours and the patient received 
7,500 cc. of blood. 

Visitors to China have also studied the Chinese programs for treating 
severe burns based on a team approach. They have been impressed with 
the mobilization of both material and human resources to save the life 
of an ordinary worker. Comparison of mortality rates in the United 
States and those reported from China suggest that the all-out team ap- 
proach as used in China may give better results than methods used in 
the United States. 

No discussion of surgery in China would be complete without refer- 
ence to the Canadian thoracic surgeon, Norman Bethune. While serv- 
ing in the field during the Spanish Civil War, Bethune developed the 
first mobile blood transfusion service in the world. He joined Mao 
Tse-tung's army medical corps in 1938 and died of sepsis in the field. In 
China Bethune was described as "The White-one Sent." He has been 
literally deified by Mao and many young surgeons have tried to emu- 
late Bethune's burning zeal and spirit of self-sacrifice: 

"Comrade Bethune's spirit, his utter devotion to others without any thought 
of self, was shown in his boundless sense of responsibility, in his work, and 
his boundless warmheartedness towards all comrades and the people. Every 
Communist must learn from him'' (Mao, December 21, 1939, Vol. II, pp. 
337-38). 

On June 26, 1965, Mao Tse-tung decreed: "In medicine and public 
health put the stress on the rural areas." Doctors, nurses, and auxilia- 
ries moved out of the great cities to establish hospitals and training 
programs in the countryside. At first their surgery was restricted to 
minor operations in the homes of the peasants. But when it became evi- 
dent that surgical infection was not a major problem, the scope of this 
"cottage surgery" was extended to major operations. 

With the massive movement of hospitals and personnel from the cit- 
ies to make-shift rural facilities, surgical training programs have 
changed significantly. 

Residency training programs seem to place special emphasis on trau- 
matology and on orthopedics. There are also postgraduate courses ot 
one year duration for doctors and nurses. 

When representatives of the American press visited China in 1971 
they were struck by the strong emphasis placed on accomplishments in 
surgery. Their schedules called for more time in surgical theaters than 



SURGERY PAST AND PRESENT 59 

in temples and other tourist attractions. Renal transplants seem to be a 
special surgical showpiece for visitors. 

Surgical Missionaries 

The surgical accomplishments of Chinese medical and surgi- 
cal teams in Tibet and in Africa have been heralded widely. A surgical 
team in Somalia performed heroic operations under the most difficult 
and demanding circumstances: splenectomy in portal cirrhosis and 
repair of vesico-vaginal fistula. They also trained Somali medical 
assistants to perform hemorrhoidectomy and hernioplasty. 

Barefoot Doctors 

The training program of the barefoot doctors places an 
early emphasis on emergency procedures. The China Pictorial in 1969 
reports that after just a little over two months of training those study- 
ing surgery are able to perform debridement and suture of wounds as 
well as surgery for lipoma and appendicitis. The curriculum includes 
a section on emergency treatment with the reduction and immobiliza- 
tion of fractures. 

On the other hand their training also includes the memorization of 
the "three constantly read articles" by Chairman Mao: "Serve the Peo- 
ple," "In Memory of Norman Bethune," and "The Foolish Old Man 
Who Removed the Mountains." 

Neurosurgery 

Features of Western and Russian neurosurgery are said to be 
combined in China. In the treatment of hydrocephalus the Russian 
procedure of omento-dural anastamosis is popular. Continuous ven- 
tricular drainage is continued for as long as one week after surgery 
for gliomas. 

Cerebrovascular accidents are the more frequent acute circulatory 
problems in China. Surgical intervention is used when the hemorrhage 
is localized or progressive but cases with ventricular hemorrhage are 
not operated on. 

In the summer of 1962, Wilder Penfield, the world renowned neuro- 
surgeon and professor of neurosurgery, visited China and reported: "it 
is fair to say that clinical brain surgery in China's best medical centers 
is as good as it is anywhere in the world" (Penfield 1963, p. 1157). 

Treatment of Fractures 

For a millenium the Chinese have treated fractures through 



60 MEDICINE AND PUBLIC HEALTH 

indigenous techniques based on gradual reduction and partial im- 
mobilization. The joints above and below the fracture are not im- 
mobilized. Instead of a single manipulation under anesthesia, the 
broken ends of bone are gradually brought into alignment by digital 
pressure. Partial immobilization is achieved by applying short splints 
around the site of the fracture. 

The patient is encouraged to exercise the injured limb to avoid mus- 
cle wastage. 

A British visitor to Peking in 1970 fractured his wrist while climbing 
the Great Wall and received what he described as excellent care at the 
Chinese Anti-Imperialist— formerly PUMC and now the Capital— Hos- 
pital. The main request from the orthopedists who attended him was 
for Western surgical journals. 

Accomplishments in medicine and public health are major propa- 
ganda instruments for the Chinese government— to a degree that is 
probably unequalled in history. While surgery was actively disdained 
in China for many centuries, today it shares with acupuncture anesthe- 
sia the pedestal in Chinese medicine. (The claims for success with acu- 
puncture as a therapeutic agent in surgical diseases and as an anesthetic 
are considered in another article; see J. Chen.) 



SURGERY PAST AND PRESENT 61 

BIBLIOGRAPHY 

Allan, T., and Gordon, S.: The Scalpel, The Sword. Boston: Little. Brown. & Co.. 

1952. 
Archives and Reprints of the Peking Union Medical College. China Medical Board 

of New York, Inc., New York City. 
Bowers, J. Z.: "Medicine in Mainland China: Red and Rural." The Pharos 33. 

No. 4. 1970. 
: "The Founding of Peking Union Medical College: Policies and Personalities." 

Bulletin of the History of Medicine 45. No. 4: 305-321 and No. 5: 409-429 (July- 
August, September-October), 1971. 
China Pictorial 6., 7-8, 1970 and 1971. 
China Reconstructs 18., September, December 1969. 
China's Medicine 10., October and November 1968. 
Cranmer-Byng, J. L., ed.: "Dr. Gillan's Observations on the State of Medicine, 

Surgery and Chemistry in China." An Embassy to China: Being the Journal Kept 

by Lord Macartney, 1793-1794, pp. 279-293. London: Longmans, 1962. 
Croizier, Ralph C: Traditional Medicine in Modern China. Cambridge: Harvard 

University Press, 1968. 
Eliot, Charles W.: Some Roads Towards Peace: A Report to the Trustees of the 

Endowment. Washington, D.C.: Carneige Endowment for International Peace, 

Publication No. 1, 1914. 
Ferguson, Mary E.: China Medical Board and Peking Union Medical College: A 

Chronicle of Fruitful Collaboration, 1914-1951. New York: China Medical Board 

of New York, Inc., 1970. 
Horn, J. S.: Away with all pests. . . . London, New York, Sydney, and Toronto: Paul 

Hamlyn, 1969. 
Liang, P. K.: "On Chinese Medicine." The People's Tribune 6, No. 11 (June 11. 

1934). 
"The Mao-Liu Controversy over Rural Public Health." Current Scene 7, No. 12 (June 

15, 1969). 
Mao Tse-tung: "In Memory of Norman Bethune." Selected Works, Vol. 2, December 

21, 1939. 
Medical Workers Serving the People Wholeheartedly. Peking: Foreign Language 

Press, 1971. 
Medicine in China: China Medical Commission of The Rockefeller Foundation. New 

York, Chicago: University of Chicago Press, 1914. 
Nathan, Carl F.: Plague Prevention and Politics in Manchuria, 1910-1931. Cambridge: 

Harvard East Asia Monographs, 1967. 
Needham, Joseph, and Liu Gwei-djen: "Chinese Medicine" in Medicine and Culture, 

F.N.L. Poynter, ed. London: Wellcome Institute of the History of Medicine, 1969. 
Peking Domestic Service, June 25 and July 8, 1969. 
Penfield, W.: "Oriental Renaissance in Education and Medicine." Science 141: 

1153-1161, 1963. 
People's Daily, July 8, 1969. 
Personal conversations with former faculty and students of Peking Union Medical 

College. 

Quotations from Chairman Mao Tse-tung. Peking: Foreign Language Press, 1966. 
Veith, Ilza: Huang Ti Nei Ching Su Wen, The Yellow Emperor's Classic of Internal 
Medicine. Berkeley and Los Angeles: University of California Press, 1966. 



62 MEDICINE AND PUBLIC HEALTH 

Wallnofer, H., and von Rottauscher, A.: Chinese Folk Medicine. New York: Crown 

Publishers, 1965. 
Welch, William H.: "Medicine in the Orient." Papers and Addresses. Baltimore: 

The Johns Hopkins Press, 1920. 
Willox, G. L.: "Contemporary Chinese Health, Medical Practices and Philosophy." a 

paper delivered at the China Conference, February 1960, at the University of 

Chicago, 1960. 
Wong, K. Chimin, and Wu Lien-teh: History of Chinese Medicine. Tientsin, 1932. 
Wu, Lien-teh: Plague Fighter: Autobiography of a Chinese Physician. Cambridge, 

England, 1959. 



ACUPUNCTURE 



James Y. P. Chen, M.D. 



I. INTRODUCTION 

Acupuncture is an ancient Chinese art of healing by inserting 
fine needles in the body at certain well-defined points. By definition, 
the Chinese term for acupuncture, chen chiu, includes not only the 
use of chen or needles, but also chiu of moxibustion, which may be 
interpreted to be a form of healing by applying burning moxa, 
(Artemisia vulgaris) on the skin. The basic Chinese medical and 
philosophical concepts, namely, the meridians, the acupuncture points 
and the doctrines of Yin- Yang and the Five Elements, are so alien to 
Western medicine that this system of therapy has generally been deemed 
unscientific and dismissed as mere superstition, witchcraft, placebo or 
even hypnosis. 

The idea that a fine needle pricking the skin in the middle of the 
back of the knee can in a few minutes relieve a long-standing low-back 
pain, that one painlessly pierced at a point on the back of the hand 
near the base of the thumb (between the thumb and the index finger) 
can relieve toothache or even induce anesthesia for tonsillectomy (Fig. 
1), or that one placed in the skin about three inches below the kneecap 
just outside the tibia can relieve stomach ache, cure gastritis, combat 
general fatigue and, at the same time, conserve robust health, may 
sound fantastic to the Western mind. Nonetheless, the experience of 
those knowledgeable in acupuncture either as a doctor, patient, or ob- 
jective observer seems to confirm some, at least, of these claims. 

Today, in the People's Republic of China, Chinese herbal medicine 
and acupuncture are undergoing extensive clinical use and research. 
Western trained physicians and traditional doctors are obligated to 
work together and combine their efforts in teaching, research, and pa- 
tient care. l < 2 > 3 

63 



64 



MEDICINE AND PUBLIC HEALTH 




Figure 1. Use of acupuncture between index finger and thumb before tonsillectomy. 



The current upsurge of interest in acupuncture in this country is 
generated by increasing reports from scientifically-trained Western ob- 
servers visiting China. Of particular significance are those reports on 
the amazing effectiveness of acupuncture anesthesia witnessed by the 
first American scientists and physicians admitted to that country in 
twenty years. In the light of these new developments, traditional 
Chinese therapeutic acupuncture needs to be re-evaluated and its rela- 
tionship to modern Western medical science put in proper perspective. 

Acupuncture is a very complex subject to interpret and study, espe- 
cially for those without a knowledge of the Chinese language and cul- 
ture. The purpose of this paper is to attempt to familiarize the reader 
with the essence of this traditional Chinese system of treatment as well 
as its current status and new developments in modern China. 



ACUPUNCTURE 65 

II. A BRIEF HISTORY OF ACUPUNCTURE 

The oldest known document on Chinese medicine is Huang 
Ti Nei Ching Su Wen, or The Yellow Emperor's Classic of Internal 
Medicine* Written about 200 B.C., this classic is a collection of dia- 
logue between the Yellow Emperor and his court physician, Chi Po, 
stressing the medical importance of Yin and Yang, acupuncture, moxi- 
bustion, and other ancient medical practices. The earliest acupuncture 
needles were fashioned of stone. Later, porcelain needles were intro- 
duced but were subsequently replaced by metal needles. The develop- 
ment of acupuncture received major impetus during the T'ang (618-907 
A.D.) and the Sung (960-1276 A.D.) dynasties. It was during this 
period that the first illustrated acupuncture document with anatomical 
drawings was evolved, 5 and the first bronze human stature with 
marked points was cast. Moxibustion at this time was already a well 
developed art which led ultimately to its use in close association with 
acupuncture. During this period, 1 1 organs of the body and their re- 
spective meridian lines had been designated: the heart, liver, spleen, 
lungs, kidneys, stomach, gall bladder, large intestine, a small intestine, 
bladder, and the tri-heaters (triple warmer) . A twelfth was later added, 
that of the pericardium (heart constrictor) . During the Yuan Dynasty 
(1280-1368 A.D.) , two more meridians were added; the Je Mei, Meri- 
dian of Conception Vessel and the Tu Mei, Meridian of the Governing 
Vessel. 6 

The principles and concepts of the various specialties embodied in 
traditional medicine, including acupuncture, remained unchallenged 
throughout its period of development until the beginning of the twen- 
tieth century. At this time, the introduction of scientific Western medi- 
cine in China led to severe criticisms of traditional medical practices as 
false and dominated by superstition. This attitude was prevalent 
among the modernists and the new Western-trained intellectuals and 
professionals. Nevertheless, despite censure, acupuncture continued to 
enjoy acceptance for its value and effectiveness in mass healing and 
treatment during national emergencies and wars and during peacetime 
in other countries such as Japan, Korea and Vietnam. Following the es- 
tablishment of the People's Republic of China, traditional medicine 
was restored to its former national esteem by decree, obligating both 
traditional and Western-trained practitioners to work side by side and 
integrate their talents. 

A. Worldwide Spread of Acupuncture Practice 

Acupuncture and moxibustion are not only encouraged and 
popularized in mainland China, but also in other oriental countries. 



66 MEDICINE AND PUBLIC HEALTH 

More recently, acupuncture spread to Western Europe and Latin 
America. While it was primarily moxibustion that spread to East 
Asia, particularly Japan, only acupuncture took hold in Europe. Acu- 
puncture was first introduced to France in 1929 through the translations 
of the French sinologist, the late George Soulie de Morant, French 
Consul in Shanghai from 1907 to 1927. There are at present about 600 
French M.D. acupuncturists, according to Dr. Jean-Claude Tymowski, 
President of the International Society of Acupuncture. 7 Acupuncture 
consultations are held widely in Paris hospitals, municipal dispensaries 
and elsewhere. Germany, Austria, England, Belgium, Brazil, Switzer- 
land, Italy and Argentina also have associations under the patronage of 
the International Acupuncture Society. 8 In recent years, acupuncture 
also attracted the attention of Soviet doctors. In 1956, the USSR sent 
several doctors to China to study acupuncture. In 1959, these Russian 
physicians published a translation of the Textbook of Modern Acu- 
puncture and Moxibustion (Hsin Chen Chiu Hsueh) , authored by Dr. 
Chu Lien. 9a Reports from the USSR indicate that a number of cases 
of trigeminal neuralgia have been cured with acupuncture. 10 

In the United States, acupuncture was regarded with only a passing 
curiosity, being sustained primarily by non-licensed practitioners of the 
oriental communities. It was not until very recently that the admit- 
tance of Western physicians to China spurred a new excitement and in- 
terest in this ancient Chinese practice— especially in the remarkable 
claims for acupuncture anesthesia. 

III. PHILOSOPHICAL BASIS OF CHINESE TRADITIONAL 
MEDICINE 

A. Ch'i, the Energy of Life, and the Principle of Yin-Yang 

According to the ancient Chinese treatise, Su Wen, "the Yin 
and the Yang are contained within the Ch'i, the basic principle of the 
entire universe. They create all matter and its mutations. The Ch'i is 
the beginning and the end, life and death, and it is found within the 
Temples of the Gods. If you wish to cure disease, you must find the 
basic cause." 

Chinese medical and philosophical teaching is based on the concep- 
tion that, in a healthy body, there should be a free and uninterrupted 
flow of Ch'i which, starting from the lungs, flows through the meridians 
in a certain order. This is best illustrated in a chart in Mann's new 
book. llil Vital energy is governed by the interplay of two opposing 
forces, the Yin (negative) and the Yang (positive). Disease results 
from their imbalance. Yin represents night, cold, dark, female, and the 



ACUPUNCTURE 67 

interior of the body; whereas Yang denotes day, heat, light, male, and 
the exterior of the body. Likewise, the 12 basic organs and meridians 
through which either the Yin or Yang energy flows are divided into the 
Yin solid (Tsang) organs which "store but do not transmit" and the 
Yang hollow (Fu) organs which "transform but do not retain" as fol- 
lows: 

Yin Yang 

Liver Gall Bladder 

Heart Small Intestine 

Spleen (Pancreas) Stomach 

Lung Large Intestine 

Kidney Rladder 

Pericardium Tri-Heaters 

(Heart-Constrictor) (Triple Warmer)* 

These two opposites are never absolute or static. One is constantly 
changing into the other. There is always some Yin in the Yang and 
some Yang in the Yin. 

B. The Doctrine of the Five Elements 

Like the principle of Yin and Yang, the doctrine of the Five Ele- 
ments also provided deep roots from which sprang basic Chinese medi- 
cal concepts and terminology used in relation to diagnosis and treat- 
ment of disease. In fact, according to very ancient Chinese tradition, all 
the phenomena of nature, including harmony between Man and Uni- 
verse, can be related to the Five Elements: Wood, Fire, Earth, Metal 
and Water. These elements can exist in a helpful relationship to each 
other or they can work against one another. The interplay of these five 
forces is illustrated in the chart of a pentagonal cycle (Fig. 2) with the 
elements succeeding each other in a clockwise rotation, as represented 
by the outer lines. This is the shen or the creative cycle for each ele- 
ment succeeding it, as the mother (Mm) engenders her son (Tse). The 
inner dotted lines in the form of a star represent Ko or destructive 
cycle. These relationships may be explained by the fact that Wood 
burns to create a Fire; the ashes left behind from the burned wood 
create Earth; from which Metal may be created; which, if heated, be- 
comes molten like Water, which would nourish and create Wood. llb 

Likewise, the structure of the destructive cycle is developed from sim- 
ilar reasoning. Thus: Wood destroys Earth by covering it; Earth de- 
stroys Water by damming it; Water destroys Fire by extinguishing it; 
Metal destroys Wood by cutting it. 



*This is a translation of the Chinese expression, referring to the intersection of the 
three meridians running across the chest. 



68 



Liver 



Creates 



MEDICINE AND PUBLIC HEALTH 

Gall bladder 

Destroys 



Kidney v 



Bladdei 



/ 



WATER 





W--r-\-~& 



Lung 



\ 





/ 



Heart. 



METAL 



EARTH 



Large 
intestine 



/ 
\ 



IRE Pericardium 

Small 

intestine, 

Tri-Heaters 



Spleen 



Stomach 



Figure 2. Chart of Pentagonal Cycle 



In the actual practice of acupuncture, this law of 
as related to the Yin and Yang organs is applied as 

Yin 

Wood corresponds to the Liver and 

Fire corresponds to the Heart and 

Earth corresponds to the Spleen and 

Metal corresponds to the Lung and 

Water corresponds to the Kidney and 

Fire corresponds to the Pericardium and 



the Five Elements 
follows: 

Yang 

Gall Bladder 

Small Intestine 

Stomach 

Large Intestine 

Bladder 

Tri-heaters 



Primitive as it may sound this concept properly applied by experi- 
enced acupuncturists has been achieving seemingly remarkable medical 
results as witnessed most recently by U.S. visitors to the People's Repub- 
lic of China. Felix Mann, the well-known British M.D. acupuncturist, 
expresses in scholarly fashion in the new edition of his book: "This law 
may seem to Western minds like the fanciful application of philosophi- 
cal law. Nevertheless, it operates whether one wishes it or not, provided 
the conditions of its working are complied with." llc 

1. The Five Elements and Acupuncture Points 

On each meridian there are specific points corresponding to 
the Five Elements. Those acupuncture points which lie in between the 
finger tips and the elbow and between the tips of the toes and knees 
have been found most important and frequently used, as shown in 



ACUPUNCTURE 69 

Table 1. Practically all diseases can be treated by appropriate use of 
these points in accordance with the doctrine of the Five Elements. 

The arrangement of the Five Elements on the limbs is fundamental to 
that of the points of tonification and sedation. According to the 
Mother-Son rule, the point of tonification of the meridian and the ele- 
ment to be tonified is a "mother" (i.e., preceding) point. Likewise, the 
point of sedation of the meridian and element to be sedated is a "son" 
(i.e., following) point. lld 

For example: (a) In the case of low-back pain, the bladder or kidney 
meridian is involved because, according to the Chinese, the back is re- 
lated to the bladder and kidney. Pain signifies overactivity and, there- 
fore, should be sedated. The kidney meridian belongs to the element 
water which should be sedated. By the Mother-Son rule, water is se- 
dated or destroyed by the element earth, therefore, the earth point of 
the bladder meridian, B54 (Wei Chung), is the spot to be used; (b) If 
the patient is suffering from palpitation of the heart or tachycardia, the 
heart is overactive and, therefore, should be sedated. The heart merid- 
ian is a fire meridian. Fire is sedated by earth, so the earth point of the 
heart meridian, H7 (Shen Men), would be used; (c) In the case of 
stomach ulcer, usually indicating hyperactivity of the stomach, the 
stomach meridian, which belongs to the element earth, should be se- 
dated. Earth is destroyed or sedated by wood, so the wood point of the 
stomach meridian itself, S43 (Hsien Ku), should be tonified to sedate 
earth (stomach). Likewise, the liver (wood) is opposed to the stomach, 
according to the law of the Five Elements; therefore, its wood point, 
Liv 1 (Ta Tun), should be tonified to destroy the element earth. 

IV. THE MERIDIANS AND ACUPUNCTURE POINTS 

The theory of traditional Chinese medicine maintains that 
inside the body there is a network of channels which are identified 
with the internal organs and the limbs and which connect the differ- 
ent parts of the body. This network is known as the Ching Lo or 
Meridians. The trunk lines which run vertically are called Ching Mai 
and the branches that run horizontally are called Mai Lo. Numerous 
spots or hsiieh in the body are distributed along the Ching Mai. 

There are some 500-800 acupuncture points or spots as shown by var- 
ious Chinese and Japanese charts. Exactly 669 points are listed in Dr. 
Chu Lien's Hsin Chen Chiu Hsueh, a standard textbook on acupunc- 
ture 6 used in present-day China. Many new points have been discov- 
ered in China in recent years. Also, master acupuncturists usually have 
a number of "secret points." The names of these points, in Chinese, 
were taken from astronomy, anatomy, geography, physiology, etc. In 
France, Germany or England the points are numbered along the line of 



70 



MEDICINE AND PUBLIC HEALTH 



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ACUPUNCTURE 7 1 

a particular meridian. For example: Li 4 represents the fourth point on 
the Large Intestine Meridian, or its equivalent, Ho Ku in Chinese. 

The primary meridians are further subdivided into classes which re- 
late to their courses of travel and the organs which they influence. 
These may simply be represented by the following categories: 

The three Yin Meridians of the arms, called the San Shou Yin Ching, 
running from the breast to the hand, are those of the lungs, heart, 
and the heart-constrictor (pericardium); 

The three Yang Meridians of the arms, called the San Shou Yang 
Ching, that run from the hand to the face, are those of the large in- 
testine, small intestine, and the tri-heaters; 

The three Yang Meridians of the legs, called the San Tsu Ya?ig 
Ching, that run from the face to the foot, are those of the stomach, 
bladder and the gall-bladder; 

The three Yin Meridians of the legs, called the San Tsu Yin Ching, 
that run from the foot to the breast, are those of the spleen, kidneys 
and the liver. 

Limitation of space does not permit a detailed description of the 
complex meridians, their organic relationships and the profusion of 
acupuncture points described along each meridian. The length of each 
meridian and the number of significant points along each course vary 
widely. For example, the Meridian of the Bladder is the longest and 
possesses 67 points. Starting at the face, this meridian winds around the 
head and neck and courses down the spinal column to the coccyx. From 
this point it ascends to the outside of the shoulder blades and descends 
again parallel to its original descent pathway, reaching the posterior 
surface of the legs and terminating at the fifth toe. The Meridian of the 
Heart has only nine points. It commences at the armpit, descends along 
the anterior surface of the arm and terminates at the little finger. 

A. Rules of Acupuncture 

From centuries of experience, the Chinese have established 
certain general rules concerning the choice of points to be used for the 
treatment of various illnesses. Some of these have been put in rhymes 
or songs to facilitate learning. The most popular one translated literally 
into English is shown in Fig. 3. The rhyme advises that, for diseases of 
the stomach and abdomen, the point of Tsu San Li should be used; 
for lumbo-dorsal ailments, Wei Chung; for women's diseases, San Yin 
Chiao, etc. 

In actual practice, the acupuncturist will generally combine a spot 
with some other sensitive spots near the source of illness. For example, in 
headaches, the T'ai Yang spot on the head is combined with the Ho Ku 



72 



MEDICINE AND PUBLIC HEALTH 



spot on the hand. In most cases, one main spot is combined with several 
secondary ones. Sometimes one spot is sufficient, but a suitable combina- 
tion of different spots reportedly produces an even stronger effect. 

The proper application of the acupuncture technique requires attain- 
ing dexterity in needle manipulation to produce a stimulating (tonifi- 
cation) effect or a tranquilizing (sedation) effect at the points of inser- 
tion. Certain illnesses require a tonifying of the points while others 
may call for sedation. 

The Chinese Law of Pa Hsieh governs the relations between tonifica- 
tion and sedation; Pu representing tonification and Hsieh representing 
sedation. The recommended technique for tonification is to rotate the 
head of the needle by pushing the thumb forward while drawing the 
index finger back (clockwise) whereas, in sedation, the head of the 
needle is rotated by pushing the index finger forward while draw- 
ing the thumb back (counter clockwise). Several other techniques such 
as "expiration-inspiration," "fast-slow," "upstream-downstream" can 
also be used to produce the tonification-sedation effect. 



at m e 

STOMACH ABDOMEN SAN 



LI 



STAY 



IT 

LUMBO — DORSAL 



HEAD 



m 



NECK 



P 

MOUTH 



WEI 



SEEK 
HO 



CHUNG 


REQUEST 


LIEH 


ft 

CH'UEH 


KU 


ft 

COLLECT 



it H 



WOMAN 



CHEST 



CAVITY 



SAN 



tt ft 



NEI 



YIN 



KUAN 



CHIAO 



PLOT 



Figurf 3. General rule for choice of points put into rhyme. 



ACUPUNCTURE 73 

The most important rules of acupuncture as summarized by Dr. Chu 
Lien are as follows: 

1. Insertion of the needle into those points located symmetrically on, 
and common to, both left and right halves of the body. For example, 
for stomach ailments use Tsu San Li (S 36) bilaterally. 

2. Insertion of the needle at points with a similar effect on both the 
upper and lower extremities, such as combining Ho Ku (Li 4) with 
Tai Ch'ung (Liv 3) for weakness of upper and lower limbs. 

3. Simultaneous stimulation of the front of the body and the back. 
In this connection, mention should be made of a combination of 
superficial and deep acupuncture whereby points on the front part of 
the body and on the back, for example, are punctured at the same 
time, but to varying depths: for example, combine Tsu San Li (S 36) 
with San Yin Chiao (Sp 6) to regulate functions of internal organs. 

4. Simultaneous "internal" and "external" treatment of a Yin point 
and a Yang point at the same time. For instance, combine Nei Kuan 
(P 6) with Wai Kuan (T 5) for stimulation of the whole arm. Ex- 
ample: Combine Ch'u Chih (Li 11) and Ho Ku (Li 4) with Yang 
Hsiang (Li 20) for treating nose ailments. 

5. A combination of direct and indirect stimulation; that is, simulta- 
neous stimulation of a point near the seat of a disease and one re- 
mote from it. 

6. Simultaneous stimulation of points along the spinal column and 
on the extremities. 

7. In the case of varying symptoms, simultaneous stimulation at vari- 
ous points. Example, for low-back pain and indigestion, use Huan 
Tiao (G 30)an d Tsu San Li (S 36), etc. 

8. "General strengthening." This is based on simultaneous stimula- 
tion of the points treated for tonification purposes and those which 
"belong" to the illness in question. 

9. Treatment in accordance with the "corresponding and changing 
time." This implies a change in the choice of points of tonification 
or sedation during the period of treatment. 6b ' 9b 

B. Pulse Diagnosis 

Pulse diagnosis plays an important role in acupuncture treat- 
ment since the condition of specific organs must be determined by feel- 
ing the pulse. An experienced Chinese traditional practitioner takes 
the pulse not only to determine heart rate, but he is reputed to be able 



74 MEDICINE AND PUBLIC HEALTH 

to ascertain whether internal organs relating to a known or suspected 
illness are in good or bad "health." The radial artery is traditionally 
the primary artery used in pulse taking. It is reported that many years of 
practice traditionally are required before pulse diagnosis may be per- 
formed proficiently. 

C. Acupuncture Needles and Techniques 

Currently, stainless steel needles are most commonly used, 
although needles made of silver and gold are still quite popular in 
France. 

In practice, three types of needles are employed (Fig. 4): the hao-chen 
needles for insertion; the seven-star or five-star dermal pi fu chen nee- 
dles for light tapping in the area of acupuncture point or on children; 
the san ling chen triangular needle for releasing blood. 

Needles for insertion are used in different lengths and thicknesses, 
depending on the desired type of insertion and depth and intensity of 
stimulation. 

The needles can be inserted at three main angles: a 90-degree angle 
at the point of insertion is used for most points; a 12 to 15-degree inser- 
tion is used for some points on the face, head, and neck; and a 45-de- 
gree insertion is used mostly for points on the chest. 

The depth of insertion, usually ranging from 3 to 10 millimeters, de- 
pends on the location of the points. In certain cases, needles of 6 to 7 
inches are used for deep muscular insertion. 

Insertion of the needle can be carried out in a number of ways. For 
example, when short needles are used, the acupuncturist can press his 
thumb on the skin near the point of insertion and then insert the nee- 
dle alongside it. With long needles, using the thumb and the index 
finger (or the index and middle finger) of his left hand, the doctor 
presses down the skin in such a way that the point is located between 
the top sections of each finger. The needle is then guided down between 
the fingers. 

Varying degrees of stimulation can be obtained by different ways of 
insertion. For example, the needle can simply be pierced in. The most 
common way is the rotated insertion, in which the needle is twirled in 
with the thumb and index finger of the right hand as the needle is 
pressed down. This method usually produces greater stimulation. 

According to old Chinese medical guidelines, there are many spots 
or areas where the use of needles or moxibustion techniques are prohib- 
ited. These areas generally are those in which arteries, veins or impor- 
tant organs are located. 



ACUPUNCTURE 



75 



V. MOXIBUSTION 

As previously mentioned, moxibustion is integrally related 
to acupuncture by the latter's definition in Chinese. Very briefly, we 
may say that moxibustion is more frequently used for chronic illnesses 
in intensifying the effect of acupuncture. Moxa, a medicinal herb 
(Artemisia vulgaris) , is known as ai (pronounced "eye") in Chinese. 
There are 4 types of moxibustion: direct, indirect, post-acupuncture 
and combined. The dry powdered herb usually is made into the shape 
of a small ball or cone which will then be placed on the actual point 
of treatment. The cone is then lit and is allowed to remain on the skin 
until the burning sensation becomes intolerable to the patient. Moxa 
may also be used in cigar form, lit, and held above the point where 




I 



I ! 



3 



Figure 4. Acupuncture Needles, 1) 2) and 3) needles for insertion— various lengths; 
4) Dermal needles with hammer; 5) Triangular needle. 



76 MEDICINE AND PUBLIC HEALTH 

treatment is to be applied. To reduce the heat intensity, insulation such 
as a slice of fresh ginger or garlic is sometimes placed between the skin 
and the burning moxa. 

VI. CURRENT STATUS OF ACUPUNCTURE AND NEW 
DEVELOPMENTS IN CHINA 

During the Great Leap Forward in 1958, Chairman Mao 
made the call: "Chinese medicine and pharmacology are a great treasure 
house. Efforts should be made to explore them and raise them to a 
higher level." Chairman Mao also urged that Western medicine be 
integrated fully with Chinese medicine. Vigorous pursuit of this na- 
tional policy has led to substantial reorientation and reform of the 
entire system of Chinese medical practice and teaching. 

A. Significant Changes 

Significant changes were observed by Western scientists and 
doctors, notably Dimond, 12 Sidel, 13 White, Rosen, and Horn, 14 during 
their recent visit to China. It is estimated that 90 percent of medical 
care in China is dispensed through the traditional system. The Western- 
trained Chinese physicians are required to learn the full range of tra- 
ditional medicine including acupuncture and pulse diagnosis (Fig. 5) . 
The traditional physician has a major role in the outpatient clinic and 
is now able to order x-ray and laboratory tests. 

Efforts were made to place acupuncture and other old traditional 
medical practices on a more scientific base through self-evaluation, re- 
search, and melding with Western concepts and approaches. Older the- 
ories and rules not verified through practical experience have been rele- 
gated to secondary orders of significance or importance. For example, in 
diagnosis and prognosis, greater emphasis is placed on effective acu- 
puncture points and their relationship to the autonomic nervous sys- 
tem, and less on the theoretical aspects of Yin-Yang, the meridians, and 
the Five Elements. 

The development of acupunctural anesthesia led naturally to its 
adoption and application to Western surgical technique and related 
diagnostic instrumentation and equipment. Though sometimes crude 
by comparison to U.S. standards, the scientific hardware available is 
nevertheless adequate and effective. Also conspicously evident is the full 
recognition of Western concepts of medical hygiene and sanitation as 
demonstrated by the sterilization of acupuncture needles and the main- 
tenance of a sterile environment where required in medical treatment. 
In medical teaching, modern anatomical charts (Fig. 6), figures (Fig. 



ACUPUNCTURE 



77 



'\ 




Figure 5. An old doctor of traditional Chinese medicine teaching the doctors of 
Western medicine how to feel the pulse ("Medical Workers Serving the People 
Wholeheartedly," Foreign Languages Press, Peking, 1971). 



7) and models (Fig. 8) and textbooks with modern terms are used in 
furthering the development of acupuncture. 

Western researchers and doctors have achieved some advances in 
bridging the gap between old and new, theoretic and pragmatic, philo- 
sophic and scientific, and between literary and technologic. Perhaps the 
most outstanding scientist with a Western background and one primar- 
ily responsible for the evolution of acupuncture in China to its cur- 
rent level is Dr. Chu Lien. Her Hsin Chen Chiu Hsueh or Textbook of 
Modern Acupuncture and Moxibustion (1957) is a standard textbook 
on acupuncture used throughout China today. This noted work, which 
has been translated into Russian, provides many new ideas and reap- 
praisals of practical techniques. 

During the past 20 years, modern research efforts in China, the Soviet 
Union and Europe to date have not provided conclusive scientific proof 
of the anatomical existence of the traditional meridians and points, al- 



78 



MEDICINE AND PUBLIC HEALTH 



though many inferences were deduced during investigations. By means 
of highly sensitive electropotentiometers, scientific researchers in China 
have claimed that the electrical potentials of skin resistance along the 
meridians are constant and lower than the fluctuating values obtained 
elsewhere in the body. These measurements have reportedly confirmed 
that connective tissue is looser in the vicinity of the traditional acu- 
puncture points. 90 

Professor Kim Bong Han of North Korea reported his discovery of a 
special conducting system of "Bong Han corpuscles," "Bong Han 
ducts" and "Bong Han fluid" circulating in the ducts. This system was 
reportedly found to correspond to the course of acupuncture meridians. 
However, this finding could not be confirmed by Chinese investigators 
and was disputed by Kellner (International Conference on Acupunc- 
ture in Vienna) as being artifacts in the preparation of histological 
slides. lle 

It is generally agreed that some sort of neural pathway is involved in 
the action of acupuncture, especially in view of the studies demonstrat- 
ing the existence of the cutaneo-visceral reflex. Modern Chinese investi- 
gators, particularly Wang Hsueh-tai and Chu Lien, regard acupuncture 
and moxibustion as stimulation therapy. 9d 




Figure 6. Modern Acupuncture Charts 



ACUPUNCTURE 



79 




Figure 7. Plastic Acupuncture Mannikin 



80 



MEDICINE AND PUBLIC HEALTH 



B. New Developments 

1. Acupuncture Anesthesia 

The recent development of acupuncture anesthesia in China 
could be an outstanding achievement which may be attributable 
directly to the combined efforts of traditional Chinese and Western 
medical practitioners. 

In the late 1950's Chinese medical workers in Sian, Shanghai and the 
provinces of Shansi and Hopei reviewed their experience with acupunc- 
ture to control the pain of toothache, sore throat, and pain following 
tooth extraction or tonsillectomy. Then they tried acupuncture to re- 
place drugs to induce anesthesia in these minor operations and were re- 
portedly successful. Summing up this experience, they worked out the 
technique of acupuncture anesthesia. Later, they started a mass move- 
ment to use acupuncture anesthesia in clinical practice and undertake 
scientific studies of it. The technique developed was gradually im- 
proved and the variety of points that could be used increased. Origi- 
nally, needles were inserted into the body and limbs. Then medical 
workers in Nanking obtained anesthetic effects by placing needles into 
points on the ear. Successes were achieved with points on the nose at 
Huaiyin, Kiangsu province, and points in the face in Shanghai. In ad- 
ministering acupuncture anesthesia, one or more needles are inserted at 
certain points on the patient's limbs, ears, nose or face. Following a pe- 
riod of stimulation and induction, anesthesia is produced for operation 
on the head, chest, abdomen or limbs (Fig. 9). This new method, used 





Figure 8. Plastic Ear Model showing acupuncture spots relating to various parts of 
the body, e.g., 1, Rectum; 2, External Genital Organs; 3, Abdomen; 4, Chest; 5, 
Heart; 6, Eyes, etc. 



ACUPUNCTURE 



81 



in a large number of cases, has apparently proved effective, safe, simple 
and economical. As of the end of 1970, acupuncture anesthesia was ad- 
ministered to more than 40,000 patients. 13 In the course of clinical prac- 
tice, the techniques have become simpler and more effective. The nee- 
dles may be moved mechanically by hand or activated electrically. At a 
national conference on acupuncture anesthesia in Shanghai in May, 
1970, some improved techniques were discussed and a more extensive 
use of these methods was promoted. 14 

According to recent reports from Chinese literature, there are certain 
essential factors or prerequisites for successful induction and mainte- 
nance of acupuncture anesthesia: 15 > 16 

(a) Choice of spots. Basically, the spots are selected according to the 
old classic principle of "following the ching (meridian) to pick the 
spots." To be effective, the needle or needles must be applied at a point 




Figure 9. At the No. 3 Teaching Hospital of the Peking Medical College, an opera- 
tion was performed under acupuncture anesthesia on a patient suffering from cancer 
of the cardia and lower esophagus. Medical workers inserted three needles at points 
on the left ear and left forearm, and by steady stimulation induced analgesia. The 
surgeon smoothly performed a transthoracic resection of a tumor of the lower 
esophagus and greater curvature of the stomach, splenectomy and gastroesophagos- 
tomy. Throughout the operation the patient was fully conscious and breathed easily. 
His blood pressure remained constant. (China Pictorial, 1971, 11. Peking, China). 



82 MEDICINE AND PUBLIC HEALTH 

or a few points along the ching which supposedly runs through the ail- 
ing part or organ of the body. In anesthesia, the same principle applies. 

(b) It is of utmost importance to attain te ch'i (acquiring a life-giv- 
ing or dynamic force) in acupuncture treatment because it is a manifes- 
tation of the functioning of ching lo (meridians) . This means that be- 
fore the needle can yield any result after its application, the patient 
must feel sore, distended, heavy and numb over the site of needle place- 
ment, and, at the same time, the acupuncturist must feel the sensation 
that the needle in his hand seems to have been slightly "sucked in." As 
recorded in the classic Nei Ching, "to make the needle effective the im- 
portant thing is te ch'i." 

c) From experience, it has been found that a sufficient period for 
induction is essential— at least 20 minutes. 

(d) To maintain acupuncture anesthesia, it is essential to preserve 
the sense of te ch'i by continuous manipulation of the needle. 

(e) Te ch'i induced by the needle is believed to be indicative of a 
normal functional state of the nervous system as shown by various ex- 
periments. It has been observed in patients suffering from hemiplegia 
that the administration of acupuncture on their legs failed to induce te 
ch'i. Likewise, if the nerves deep in the needle insertion spots are tem- 
porarily desensitized by local anesthetic, the spots would lose their sen- 
sitivity. 

Anatomical research in the structure of the spots also shows that the 
veins pass directly underneath half of the more than 300 acupuncture 
spots in the human body, while in the other half the nerves are within a 
radius of half a centimeter. 17 

Although most of the phenomena relating to acupuncture can be ex- 
plained today in some connection with neural pathways, this does not 
mean that the theory of ching lo should be discarded altogether. For 
example, Army medical workers in Kwanchow found that needles in- 
serted on one side of the patient's body induced analgesia on the other 
side of his body in a chest operation. Since no logical neural basis can 
be attributed to this phenomenon, the ching lo theory would appear to 
offer a possible explanation. 

If indeed there is substance to the reports, in many ways acupuncture 
anesthesia could be superior to any of the conventional anesthetics. 
The most apparent advantage, of course, is that it is very inexpensive 
and very simple to handle. The method can now be used by a small 
team equipped with nothing but a few needles. Many medical orderlies 
and barefoot doctors in the villages have mastered the skill of such 
anesthetization. This would be particularly valuable for rural and 
mountainous areas and under war conditions. 



ACUPUNCTURE 83 

With acupuncture anesthesia, the patient remains in a sober state 
throughout the operation. Aside from being insensitive to pain, his 
physiological functions run normally. This enables him to better coop- 
erate with the surgeon and the latter to know more precisely how the 
patient's condition and operation are progressing. For instance, during 
the operation to correct squinting, when anesthesia has been induced 
by acupuncture, the patient's eyeball can function normally. The sur- 
geon is able therefore to ascertain the result of the operation then and 
there without having to wait, as when an anesthetic is administered, for 
the subsidence of the effects of the anesthetic drug. Another obvious ad- 
vantage is that undergoing heart surgery or a pneumonectomy with acu- 
puncture anesthesia, the patient can, as required by the surgeon, carry 
out abdominal breathing to facilitate the operation and to relieve him- 
self of discomforts which usually accompany such operations. 

For cases where the patients cannot tolerate general anesthesia, espe- 
cially in heart surgery, the advantage of the new method would be all 
the more obvious. One important difference between general anesthet- 
ics and acupuncture is that where the former renders inactive the pa- 
tient's brain and central nervous system during the operation, the latter 
activates them so that they can regulate the physiological functions of 
the patient undergoing an operation. This explains certain unusual 
phenomena connected with the blood pressure of patients under acu- 
puncture anesthesia. Recent literature from China also showed that the 
acupuncture method can be used safely in emergency operations where 
the patients have been suffering from chronic hypertension or hypoten- 
sion with feeble pulse. 

Based on recent extensive clinical observations and research in acu- 
puncture anesthesia, the Peking Acupunctural Anaesthesia Co-ordinat- 
ing Group have found that Chinglo (Meridian) and the nervous sys- 
tem, in large measure, correspond to each other. The traditional 
Chinese medical treatises maintain that Chinglo probably includes the 
nerves, blood vessels, the endocrine system and some of their functions. 
However, the theory of Chinglo concerning the connections between 
various parts of the body cannot be explained entirely by our present 
knowledge of neuro-anatomy and neuro-physiology. For instance, they 
have found that when pain is induced with thermal stimulation of cer- 
tain parts of the limbs, sensitivity to pain appears in corresponding 
areas of the ears. This shows that the points on the ears have certain 
specific connections with other parts of the body. Therefore, they consid- 
er that Chinglo includes not only nerves and blood vessels, but may 
also involve certain connecting pathways and activities inside the 
human body, and the laws governing them are still unknown. However, 
certain demonstrable physiological changes induced by acupuncture 



84 MEDICINE AND PUBLIC HEALTH 

have been observed. For instance, needling certain points on the body 
of a normal person or animal caused an increase in white blood count 
and enhanced phagocytosis. Also, needling of the tsu san-li point (ex- 
ternal side of leg just below the knee) increased intestinal peristalsis in 
fluoroscopic studies of both human and animal. 

Using modern scientific methods, the Chinese scientists and medical 
personnel have ascertained the following two main physiological effects 
of acupuncture anesthesia: (1) the analgesic effect, and (2) the regula- 
tory effect. 

Concerning the analgesic effect, extensive clinical practice has report- 
edly shown that needling certain points on the body is very effective for 
suppressing pain. Toothaches, headaches, low back pains and pains in 
the chest and adbomen could be suppressed immediately by needling 
certain points. The regulating effect is considered to be the more im- 
portant effect of acupuncture anesthesia. This effect restores abnormal 
functions of the body to their normal condition. Clinically, the Chinese 
investigators often have reported that needling the same point has cor- 
rected both diarrhea and constipation, and brings a rapid or slow heart 
rate back to normal. 

It is the opinion of the Peking Acupunctural Anaesthesia Coordinat- 
ing Group that the effect of needling in preventing and suppressing 
pain and its regulating effect are interrelated and act on each other, and 
it is "precisley these effects that help increase the patient's endurance to 
withstand the operative procedure and reduce his sensitivity to pain. 
When this kind of anesthetization is used, the patient, apart from feel- 
ing little or no pain, it reportedly fully conscious during an operation 
and can withstand its attendant trauma. This is why the relatively 
small stimulation produced by needling can overwhelm the much 
stronger stimulation resulting from surgical trauma." 

From modern scientific experiments on animals, Chinese researchers 
have recently suggested the role played by the brain in acupuncture an- 
esthesia. When pain stimulus was applied on certain parts of an ani- 
mal's body, characteristic electroencephalographic changes in a certain 
part of the cerebral cortex were observed. While simulating the process 
of performing an operation with acupuncture anesthesia, first needling 
the points and then applying pain stimulus, the researchers noticed that 
electroencephalographic changes in the cerebral cortex caused by nee- 
dling certain points could completely suppress or markedly weaken 
these changes induced by the pain stimulus. Such effects varied when 
different points were needled. The Chinese think the principle of acu- 
puncture anesthesia may be related to cerebral cortex involvement. 
Experiments have also proved that similar phenomena also occur at vari- 
ous subcortical levels of the central nervous system. "Therefore, the ef- 



ACUPUNCTURE 85 

fects of acupuncture anesthesia are in effect related to the different lev- 
els of the central nervous system, with possible participation of other 
factors, such as humoral factors."* 

2. Treatment of Blindness and Deaf-Mutism 

According to traditional teaching and practice, certain points 
around the eye and the ear are forbidden to deep needle insertion. 
However, with "revolutionary spirit," PLA medical workers reportedly 
have broken through many "forbidden zones" by deep needling and 
developed more effective techniques for the blind and deaf-mutes, as 
well as for the residual-effects of infantile paralysis. Also, many new 
points have been found for curing these defects. Recent reports from 
China indicate that in 1970 they treated 1,380 patients suffering 
from different kinds of eye defects and in 90 percent of the cases ob- 
tained good results. Among them, 111 patients who had been blind 
from several to forty years reportedly regained their eyesight by this 
new acupuncture therapy (Fig. 10) . 18 

C. Therapeutic Efficacy of Acupuncture 

1. General Ailments 

Documentation is available today in scientific journals and 
literature to suggest that acupuncture is appropriate for treating a wide 
variety of diseases, ranging from internal medicine to women's and 
children's ailments, and from neurology to organotherapy. Despite 
substantial progress achieved in expanding both the scope and the 
depth or degree of efficacy in medical treatment within recent decades, 
acupuncture is not regarded by medical doctors in China as a magic 
cure-all. They recognize with patient reality that, for certain illnesses, 
acupuncture is only moderately effective, and for certain ailments 
acupuncture has shown no effectiveness at all. However, the apparently 
spectacular successes achieved fairly recently with acupuncture, espe- 
cially in the field of anesthesia, have served to spur the Chinese scien- 
tists to greater hopes and efforts for further achievements. 

Acupuncture has been reported to be particularly useful in the treat- 
ment of functional disturbances, in the alleviation of pain, and in the 
reduction of muscular spasms. The therapeutic value of acupuncture in 
the treatment of groups or "systems" of diseases was assessed and results 
compiled from cases occurring throughout China, including Inner 
Mongolia, between 1951 and 1954. Of the 10,036 cases involving acu- 



*Peking Acupunctural Anaesthesia Co-ordinating Group, "The Principle of Acu- 
punctural Anaesthesia," Peking Review, 7-8, February 25, 1972. 



86 



MEDICINE AND PUBLIC HEALTH 




Figure 10. Many rare and diffi- 
cult cases of eye diseases have 
been successfully treated by new 
acupuncture therapy. (China 
Pictorial, September, 1970) 



puncture, 8,063 were later reviewed and the number of cases success- 
fully treated averaged 92.47 percent. 9e 

Highlights of some of the more significant Chinese scientific publica- 
tions on acupuncture that are available up to 1967 may be summarized 
as follows: 

(a) A new acupuncture spot named "Ya T'ung Ling" (toothache ef- 
fective) is claimed by the Chinese as specifically for treating toothache. 
This spot, as shown in Fig. 11, is situated between the joints of the 
middle finger and the ring finger. According to clinical reports, this 
spot has demonstrated as effectiveness greater than 95 percent in tooth- 
ache treatment. 19 

(b) Acupuncture and moxibustion are reported to be especially ef- 
fective in the restoration of limb movement after polio. Acupuncture 
and moxibustion are applied at the Yang Ming spots to relieve paraly- 
sis. 20 

(c) It is well known that Ho Ku is one of the most commonly used 
points in treating diseases such as toothache, spasm of the upper ex- 
tremities, lymphangitis, tumor of the thyroid gland, tonsillitis, paroti- 
tis, gingivitis, sinusitis and other ailments in the upper portion of the 
body. When acupuncture applied locally brings no relief in acute ab- 



ACUPUNCTURE 



87 




Figure 11. New Acupuncture 
spot effective in toothache 
(Chiang-su Chung-i, No. 7- 
1966, 40, July, 1966) 



dominal pain, such as acute and chronic colitis, appendicitis, hernia, 
prolapsed anus, etc., needling at the Ho Ku site was found to produce 
the relief desired. 21 

(d) Treatment of 280 cases of goiter with acupuncture has been re- 
ported. The majority of the patients were between 14 and 25 years of 
age. Acupuncture was administered every other day for two weeks. All 
but two were cured. One of the two cases seemed to be lymphotuber- 
culosis and the other appeared to be thyrophyma. This technique was 
applied in an entire Hsien (district) with later reports claiming that 
goiter, as a disease, has almost disappeared in that region because of 
this technique. 22 

(e) The acupuncture points of Tien Tu, Ho Ku and Shao Shang 
were found effective in the treatment of pharyngeal paralysis in 22 pa- 
tients who had not responded to conventional treatment with hot 
steam, diathermy, etc. All of the 22 patients responded to acupuncture, 
although several courses of treatment were required in some. 23 

(f) Between May, 1962 and March, 1964, 115 cases of acute jaundi- 
cial, infectious hepatitis were divided into three groups of 40, 35 and 40 
patients. One group was given acupuncture treatment; another, West- 
ern medical treatment (hepatic maintenance); and the third, joint 
Western and traditional medical treatment. Hepatic maintenance and 
build up for those treated with Western methods included administra- 
tion of vitamins and liver products. Those treated by the joint method 
were given the same hepatic maintainers, plus a traditional medicine, 
comprised mainly of Herba Artemisiae Capillaris. Results were that 
from the points of view of symptomatic relief, jaundice eradication, 
and return of liver function, acupuncture was far superior to the other 
two methods used. 24 

(g) Acupuncture therapy was applied in 12 cases of postoperative 
pain in the anal region. Eight cases showed immediate response with 
cessation of pain, three improved, and one did not respond because of 



88 MEDICINE AND PUBLIC HEALTH 

technical error. Su Ku Hsueh, located on the lateral surface of the small 
toe, was chosen as the specific anatomical point for the needle inser- 
tion. 25 

Acupuncture was applied for the treatment of 1,032 cases of infantile 
paralysis at the Peking Municipal Children's Hospital from 1953 to 
1962. Of 526 patients who received acupuncture treatment within two 
weeks of appearance of the disease, 253 were completely cured, 72 were 
nearly cured, 147 showed noticeable improvements, and 54 showed 
some improvement. The electromyograms of the patients who had re- 
ceived acupuncture treatment showed definite improvement. A greater 
number of acupuncture points in each course of treatment was recom- 
mended since a large number of muscles and muscle groups were in- 
volved. In a group of 99 patients who were given acupuncture at ten 
points in each course of treatment, 40 were completely cured. But in 
another group of 90 patients who were punctured at two to four points 
in each course of treatment, only 24 were completely cured. A diagram 
is given showing nine acupuncture points from the thigh down to the 
foot. 26 

In a study on acupuncture treatment and prevention of epidemic in- 
fluenza, the following four points were selected: Ta Chui, Nei Kuan, 
Ho Ku and Tsu San Li. Results from observations of 1,006 cases 
showed that acupuncture caused the disappearance of symptoms in pa- 
tients who had early and simple types of influenza. Fever usually began 
to fall in an hour. Five to 16 hours later, the temperature subsided to 
normal. The effect of acupuncture administered during the recovery pe- 
riod was even more pronounced. The general consensus is that acupunc- 
ture proved to be more effective than treatment with aspirin com- 
pounds alone. It is believed that acupuncture might have a prophylactic 
effect against influenza. 27 

2. Anesthesia 

As mentioned earlier, a total of over 400,000 surgical op- 
erations were reported to have been performed under acupuncture 
anesthesia with a success ratio of about 90 percent. These operations 
were performed in towns, municipalities, districts, and metropolitan 
areas throughout the country on patients ranging from infants to 80- 
year-olds. The 33rd People's Liberation Army Field Hospital recently 
published a report on the analysis of 331 cases of acupuncture anes- 
thesia performed over a 15-month period. Table 2 showns a breakdown 
of the types of surgery and the success ratios for attaining anesthesia. 
The average success ratio was found to be 95.2 percent. The best 
anesthesia results were obtained for operations in the regions of the 
head, neck and chest. The anesthesia success ratios for these series of 



ACUPUNCTURE 89 

331 operations were reported to be comparable to those attained in 
similar hospitals elsewhere in China. 

Table 2. Success Rates for Attaining Anesthesia 



Sites 


Number 




Results 




Success 


of 
Surgery 


Acupuncture 
Anesthesia 


Good 


Satisfactory 


Fair 


Failure 


/o 


Head, Neck 


94 


42 


49 


3 




100.0 


Chest 


3 




3 






100.0 


Abdomen 


162 


41 


86 


28 


7 


95.0 


Lumbodorsal 


5 


2 


2 




1 


80.0 


Perineum 


38 


14 


14 


7 


3 


92.1 


Upper Limbs 


16 


5 


6 


2 


3 


81.3 


Lower Limbs 


13 


2 


6 


3 


2 


84.6 


TOTAL 


331 


106 


166 


43 


16 


95.2 



Such success in acupuncture anesthesia, as reported, is perhaps re- 
markable when one considers that the total development and growth of 
this anesthetic approach spanned a relatively short time period. In 
1970, the Third Teaching Hospital of the Peking Medical College per- 
formed over 3,000 operations on the head, neck, chest, abdomen and 
limbs using acupuncture anesthesia— a tenfold increase over the number 
in the 8 years before the Cultural Revolution. 

VII. ENGLISH TEXTBOOKS ON ACUPUNCTURE 

In view of numerous inquiries on the availability of English 
textbooks on acupuncture, the writer recommends the following: 

1. Acupuncture, the Ancient Chinese Art of Healing, by Felix 
Mann, 1971, Second Edition (11). This is the best known and most 
complete textbook of acupuncture in the English language. Dr. Mann 
is a British M.D. who has long been a student and practitioner in the 
subject. While visiting China in 1963 as a guest of the Chinese Medical 
Association, he studied certain developments in the field of acupunc- 
ture. The first edition of this popular book has also been translated 
into Chinese in China. - s 

2. Chinese Acupuncture by Dr. Wu Wei-p'ing. 5 This is the 
first textbook of Chinese acupuncture that has ever appeared in English. 
It is an English translation from the French edition of his original 
textbook in Chinese. It is presented in a very condensed form. Dr. Wu 
is an internationally known Chinese master acupuncturist. 

3. The Chinese Art of Healing by Stephen Palos, 1971. 9 This 
is one of the first books covering traditional Chinese medicine 
in a comprehensive manner. Being a sinologist, the author gained 



90 MEDICINE AND PUBLIC HEALTH 

rapid familiarity with the subject. For this book, the Chinese Medical 
Society in Peking made available to the author Chinese material and 
research information on the traditional Chinese art of healing. 

VIM. CONCLUSION 

The universal precept in medical practice since ancient times 
has embodied the belief that beneficial cures and treatment should be 
made available to all mankind. Because of its philosophical derivation 
and its enshroudment in Oriental mysticism, acupuncture has appeared 
to be an irrational practice when viewed by Western medical science. 
During the last two decades, the development of acupuncture in China 
received a dramatic boost through official decree to integrate traditional 
and Western medicines. Only very recently, through personal observa- 
tion, has the United States medical profession been introduced to 
demonstrations of therapeutic acupuncture and acupuncture anesthesia 
for major surgical procedures, which may lead to other significant 
medical discoveries. 

The current concept held by Chinese scientists concerning the phe- 
nomenon of acupuncture anesthesia points to a possible interrela- 
tionship between chinglo (Meridian) and the nervous system, with the 
two main physiological effects being analgesic and regulatory. While 
significant advances have been made in this field, the Chinese authori- 
ties acknowledge a lack of compehensive knowledge of the chinglo the- 
ory and a full understanding of certain aspects of acupuncture anesthe- 
sia. They emphasize the need for more intensive scientific research to 
gain a better understanding of this important development. Recent 
communications between physicians and scientists of the United States 
and the People's Republic of China have established an initial bridge- 
way to provide an opportunity for improved interchange of informa- 
tion between the two countries. Results may be rewarding not only to 
the medical practice in the United States, but to medical science in 
general. 



ACUPUNCTURE 91 

REFERENCES 

1. Li, T. C: Chinese Med. J. 79: 483, 1959. 

2. Chen, J. Y. P.: "Highlights of Pharmacology in Mainland China" Ann. Rev. of 
Pharmacology 2: 11-16, 1962. 

3. Croizier, R. C: Traditional Medicine in Modern China. Harvard University 
Press, Cambridge, Massachusetts, 1968, 189-209. 

4. Veith, I.: Huang ti nei ching su wen {The Yellow Emperor's Classic of Internal 
Medicine) (new edition). University of California Press, Berkeley and Los 
Angeles, California, 1966. 

5. Wu, W. P.: Chinese Acupuncture. Health Science Press, Rustington, Sussex. 
England, (no date), 13-14. 

6. Chu, Lien: Hsin chen-chiu hsueh (Textbook of Modern Acupuncture and Moxi- 
bustion). The People's Hygiene Publishing House, Peking, China. 1957. (a) p. 2; 

(b) p. 36-37. 

7. Personal Communication. December, 1971. 

8. Huard, P. and Wong, M.: Chinese Medicine. McGraw-Hill Book Company, New 
York, Toronto, 1968, 210-211. 

9. Palos, S.: The Chinese Art of Healing. Herder and Herder, New York, 1971, 
(a) p. 101; (b) p. 113; (c) p. 76; (d) p. 114; (e) p. 116. 

10. "A Talk with a U.S. Acupuncturist." Anonymous: World Medical News, 48-49. 
February 4, 1972. 

11. Mann, F.: Acupuncture, the Ancient Chinese Art of Healing. Second edition. 
William Heineman Medical Books Ltd., London, 1971, (a) p. 49; (b) p. 77-78. 

(c) p. 79; (d) p. 90; (e) p. 5. 

12. Dimond, E. G.: "Acupuncture Anesthesia." JAMA Vol. 218, No. 10: 1558-1563, 
December 6, 1971. 

13. "Medicine in China." Medical World News, Vol. 13, No. 2: 51-62, January 
14, 1972. 

14. Horn, J. S.: "Away with All Pests." Monthly Review Press, New York and 
London, 1969. 

15. "China Discovers Acupuncture Anesthesia." China Pictorial: 2-5, November, 
1971. 

16. "China Discovers Acupuncture Anesthesia." China Reconstructs, Vol. XX, No. 
10: 2-5, October, 1971. 

17. Selections from China Mainland Magazine. No. 712, September 13, 1971. 

18. "The Blind Regain Their Sight." Anonymous: China Pictorial: 36-37, Septem- 
ber, 1970. 

19. Liang, Ch'iu: "Introduction of a New Spot "ya-t'ung-ling" in Acupuncture for 
Treating Toothache." Chiang-su Chung-i (Kiangsu Chinese Traditional Medi- 
cine) No. 7-1966, 40, July, 1966. 

20. Han, C. C, et al.: "Treatment of Polio by Acupuncture and Moxibustion." 
Chiang-su Chung-i (Kiangsu Chinese Traditional Medicine) No. 5-1966, 26-30, 
May, 1966. 

21. Chang T.: "Discussion of the Application of Acupuncture at the ho-ku Site." 
Chiang-su Chung-i (Kiangsu Chinese Traditional Medicine) No. 4-1966. 3-5. 
April, 1966. 

22. Liu, T.: "Introducing Experience of Using Acupuncture to Treat Goiter." 
Chung-i Tsa-chi (Journal of Chinese Traditional Medicine) No. 6-1960, 2223, 
June 5, 1960. 

23. Jen, S., and Chao, C. C: "Acupuncture in the Treatment of Pharyngeal Paralysis: 



92 MEDICINE AND PUBLIC HEALTH 

Report of 22 cases." Shan-tung I-k'an {Shantung Medical Journal) No. 8-1964, 
42, August, 1964. 

24. Li, Ching-chou and Chin, Ch'in: "Efficacy Observations in Acupunctural Treat- 
ment of Acute Jaundicial, Infectious Hepatitis." Shanghai Chung-i Tsa-chih 
(Shanghai Journal of Chinese Traditional Medicine) No. 2-1965: 26-28. Feb- 
ruary 15, 1965. 

25. Chang, C, and Chen, I.: "Treatment of Post-Operative Pain of Anus with 
Acupuncture." Chiang-su Chung-i (Kiangsu Chinese Traditional Medicine) No. 
2-1966, 36-37, February 1966. 

26. Chung I Tsa-chih (Journal of Chinese Traditional Medicine), Peking, No. 8- 
1964, 1-5, August 10, 1964. 

27. "Initial Clinical Observations in Acupunctural Prevention and Treatment of 
Epidemic Influenza in 1,000 Cases." Anonymous: Chung-i Tsa-chih (Journal of 
Chinese Traditional Medicine) No. 2-1964, 7-9, February 5, 1964. 

28. Personal Communication. December, 1971. 



PHARMACOLOGY 



James Y. P. Chen, M.D. 



INTRODUCTION 

The origin of traditional Chinese medicine, notably herbal 
remedies and acupuncture, is intricately interwoven with Chinese 
philosophy and history dating back thousands of years before Christ. 
Whereas tremendous strides were made in Western medicine in its 250 
years of growth, the rate of advancement of Chinese medical practice 
was extremely sluggish by comparison throughout its 3,000 years of 
development. It is only recently that, with intensified integration of 
Western and Chinese traditional medical practices in the cultural 
revolution period, herbal pharmacology has been shifted into a new 
phase of scientific development. 

Significant achievements in modern pharmacology have been re- 
ported in recent years in Chinese literature as well as by Western scien- 
tists and physicians who have been recent visitors of the People's Re- 
public of China. This new development, along with a growing curiosity 
in acupuncture and herbal medicine, account for the recent upsurge of 
interest in the ancient traditional medical practice. Special chapters 
have been assigned in this handbook for specific and detailed treatment 
of acupuncture and traditional medicine. In addition, a detailed and 
scholarly discussion of traditional medical practice is presented in Cro- 
izier's recent book, Traditional Medicine in Modern China. 1 This book 
provides extensive historical and philosophic background and points 
out the recent sociopolitical influences on traditional Chinese medical 
theory and practice. The focus of this chapter will be on the current 
status and development of pharmacology in China. Material used for 
this chapter was gathered from Chinese scientific literature, notably, 
the Chinese Medical Journal (into English); the Yao-hsueh T'ung-pao 
(Pharmacology Bulletin); and the Yao-hsueh Hsueh-pao (Acta Phar- 

93 



94 MEDICINE AND PUBLIC HEALTH 

maceutica Sinica), etc. With the cessation of publication of these scien- 
tific journals in 1967 during the Cultural Revolution, the coverage of 
pharmacological research and development has since been limited to 
the news magazines, news periodicals, and newspapers. 

To promote research and training in traditional medicine, the Acad- 
emy of Traditional Medicine was established in Peking in 1955 to coor- 
dinate the activities of various research services on acupuncture, exter- 
nal pathology, internal pathology, traditional remedies, and the history 
of traditional medicine. Subsequent integration of traditional and 
Western scientific schools through government edict in 1958 resulted in 
intensive examination and development of traditional medicine 
through modern scientific methods. The Institute of Materia Medica in 
Peking which was recently visited by American scientists and doctors 2 - 3 
is a component of the Chinese Academy of Sciences. This Institute has 
a department of pharmaceutical chemical synthesis, department of phy- 
tochemistry, department of pharmacological analysis, and department 
of pharmacological research. Thus medicinal herbs, the mainstay of tra- 
ditional medicine, received significant scrutiny and refinement in the 
development of pharmaceutical technology. The active principle of 
many important plant drugs has been identified and isolated. At the 
same time, the pharmaceutical industry has kept pace with the modern 
technology of drug synthesis. Of particular significance is the successful 
synthesis of insulin. 

In consonance with the national drive to increase agricultural pro- 
ductivity, emphasis in pharmacology was placed on the development of 
such drugs as antibiotics, drugs for common diseases, drugs for parasitic 
diseases, commonly available herbs, and practical rural medicinals. 
Chinese herbal remedies are economical and are regarded as being very 
effective in rural and industrial medicine. Numerous "secret" perscrip- 
tions, collected during work with the peasants, have been collated and 
tested by scientifically trained doctors in research institutes to find the 
basic active ingredients. A number of these have proved effective in 
clinical trials. 4 ' 5a > 2a The subject of anticancer drugs will be covered 
elsewhere in this handbook. 

Chinese Materia Medica — An Historic Review 

Chinese traditional medicine is regarded as one of the oldest 
healing practices in the world. Its pharmaceutical activity dates back 
to legendary times. The first materia medica (pen ts'ao) as compiled 
by the emperor, Shen Nung (about 2700 B.C.) , who is generally re- 
garded as the "Father of Chinese Medicine," and inventor of drug 
lore. Next, in order of merit was the pen ts'ao credited to the legendary 
emperor, Huang Ti (2600 B.C.), also called the "Yellow Emperor." 



PHARMACOLOGY 95 

The earliest pen ts'ao is said to list 365 drugs of all kinds. In the 5th 
century A.D., a physician of renown, T'ao Hung-ching, added another 
365 drugs to the early compilations, practically doubling the number 
of drugs of animal, vegetable and mineral origin. In the middle of the 
7th century A.D., Ying Kung and Su Ching were ordered by Kao Tsung, 
the third emperor of the T'ang Dynasty, to revise T'ao Hung-ching's 
materia medica. The final version of these revisions listed 844 medicinal 
items and is considered the earliest pharmacopoeia in the world. Dur- 
ing the Sung Dynasty, Tang Shen-wei, a physician, increased the num- 
ber of drugs to more than 1,746 in his Classified Materia Medica. 

A. The Compendium of Materia Medica 

The Ming Dynasty in the 16th century is regarded "the 
most glorious period in the history of Chinese pharmacopoeia." 6 The 
great progress made in materia medica was, to a large extent, attributed 
to peace and stability and a fluorishing economy in existence within 
the empire. Undoubtedly, the greatest pharmacological achievement of 
all times which occurred during this period was marked by completion 
of the monumental Pen Ts'ao Rang Mu or the Compendium, of Ma- 
teria Medica. This landmark achievement was accomplished by Li 
Shih-chen (1518-1593 A.D.) , a noted pharmacologist, physician and 
naturalist. 

Completed in 1578 A.D., after 27 years of labor, this famous compen- 
dium was compiled from a study of more than 800 books, resulted in 
careful revisions by the author of 40 pharmacological and 70 medical 
works by earlier experts, addition of 374 new drugs, and even drew from 
historical classics, poetry and fiction. In summary, Chinese pharmacolog- 
ical knowledge, from the earliest beginnings to the 16th century, was 
analyzed, dissected, reorganized and reintegrated into an exhaustive and 
comprehensive monument of reference material which has since gained 
important recognition in international science and medicine and has 
proven of inestimable value for modern use. 

The following is a reclassification of the drugs listed in the Compen- 
dium of Materia Medica. 

Animals (insects, fishes, mollusks, birds, beasts and men) 444 drugs 

Vegetable kingdom (herbs— 610; vegetables, fruits, trees— 484) 1,094 drugs 

Metals and minerals 275 drugs 

Articles of daily use (substances derived from garments and utensils 

prescribed in medicine) 79 drugs 



Total 1,892 drugs 



96 MEDICINE AND PUBLIC HEALTH 

B. Contribution of Pen Ts'ao Kang Mu 

The 374 new drugs added by Li Shih-chen in his Compen- 
dium of Materia Medica include san ch'i (Gynura pinnatifida), man 
t'uo lo (Datura alba) , fan mu pieh (Semen strychni) , ya p'ien 
(opium), shao chiu (alcohol) , p'u t'ao chiu (grape wine), chang nan 
(camphor) and ta feng tze (lucreban-seed) , which have remained val- 
uable drugs ever since. He also recorded grains and vegetables intro- 
duced into China after the tenth century A.D., such as maize, kidney 
bean, carrot, sweet potato, pumpkin and snake-gourd. 

Li Shih-chen conducted extensive research in the therapeutic prop- 
erties of drugs. It was in this area that he made the greatest contribu- 
tion to pharmacology. He not only cleared up doubtful points, but also 
made new discoveries. He found that yen hu suo (Corydalis ambigua) 
relieved pain and ch'ang shan (Dichroa febrifuga) cured malaria. 
Among his other discoveries were: the cathartic effect of ch'ien niu tza 
(Ipomaeo hederacea), the antipyretic effect of huang ch'in (Scutellaria 
baicalensis), the regulating effect of yi mu ts'ao (Leonurus sibiricus) 
on menstruation, the hemostatic effect of san ch'i (Gynura pinneti- 
fida), the uretic effect of hsiang ju (Elsholtzia cristata), and the stimu- 
lating effect of jen shen (ginseng). The Pen Ts'ao Kang Mu even today 
is a vast treasurehouse for pharmacologists engaged in research. It is 
particularly rich in drugs of vegetable origin: over a thousand varieties 
are listed. Research in modern medicine has led to the discovery of the 
therapeutic properties of numerous drugs: Ta feng tze yu (lucrabanseed 
oil) as a cure for leprosy, tang kuei (Ligusticum acutilobum) for men- 
strual complaints, ma, huang (Ephedra vulgaris) for asthma, lei wan 
(Mylitta lapidescens) and ping Jang (betel nut) kills tapeworms, tu 
chung (Eucommia ulmoides) alleviates high blood pressure, ta huang 
(rhubarb) and huang lien (Coptis teeta) are effective antibacterial 
agents, and many more. 

Since its publication in 1596, the Pen Ts'ao Kang Mu has been in 
wide circulation and reprinted many times. For over 300 years it has 
been the companion of every practitioner of Chinese medicine. It has 
acquired international fame. It reached Japan 10 years after its first 
publication, and was twice translated into Japanese, once in 1783 and 
again in 1929. Among those who either partially translated or consulted 
the Pen Ts'ao Kang Mu when writing books on China were: Michael 
Boym, a Pole who wrote Flora of China (in Latin, published in 1659): 
du Halde, a Frenchman, who wrote A Description of the Empire of 
China (published in 1735, and containing two chapters on Chinese 
pharmacology); A. Tatarinov, Russian physician and sinologist, who 
compiled the Manual of Chinese Materia Medica in 1857. An abridged 
German translation of the Pen Ts'ao Kang Mu, called Dalitsch Pflan- 



PHARMACOLOGY 



97 



zenbuch, was published in 1928. There have been ten or more English 
translations. One of them was done by B. E. Read. Its first seven vol- 
umes appeared between 1928 and 1941. 7 

Pharmacological Research and Development of Herbal 
and Synthetic Drugs 

Based on available scientific publications from China dur- 
ing the past 20 years, the more significant research and development 
in pharmacology may be presented as follows: 

A. Significant Pharmacological Achievements 
1. Drugs Against Parasitic Diseases 

In 1958, a comprehensive survey of the Achievements in the 
Fight Against Parasitic Diseases was reported by Hou, et al. 8 Nation- 
wide campaigns were conducted for the eradication of the five major 
parasitic diseases in China; namely, schistosomiasis, malaria, filariasis, 
ancylostomiasis, and kala-azar. Of these prevalent diseases, the greatest 
emphasis has been placed on schistosomiasis, as indicated by the abun- 
dance of literature on new and effective antischistosomal compounds. 
Of the new drugs synthesized and screened, the following were 
reported to be more promising antimonials: antimony ammonium glu- 
conate, antimony sodium dimercaptosuccinate, and antimony dithio- 
propionate and thiouracil-antimony-1. Of the non-antimonial prepa- 
rations rosaniline, hexachlorophene, and para-amino-oxybenzeneheptane 
were reported to have therapeutic potential. More recently, two newly 
discovered non-antimonial chemotherapeutic agents, coded as F30066 
and F30069 (nitro-furan type) have been claimed to be highly effective 
oral anti-schistosomal agents. 9,10 

Among the Chinese herbal remedies, cucurbita pepo (pumpkin 
seeds) and wild daylily were found to possess definite therapeutic effects 
in experimental and clinical schistosomiasis. The effectiveness of pump- 
kin seeds was said to be enhanced by the concomitant use of antimony 
potassium tartrate. Pumpkin seeds were claimed to be safer and more 
effective than antimony potassium tartrate. 11 ' 12 > 13 

With regard to other parasitic diseases, in vivax malaria radical cure 
reportedly was achieved in almost 100 percent of large series of cases 
treated with primaquine (15 mg. daily for 14 days) combined with 
chloroquine (300 mg. daily for the first four days) or cyclochloro- 
guanide (a total dosage of 600 mg. given in four days). In a controlled 
group given chloroquine alone, there was a relapse rate of 50 percent. 
Of the medicinal plants, Orixa japonica, T. and Brucea javanica, L. 
showed a significant antimalarial activity in experimentally infected an- 
imals. 14 



98 MEDICINE AND PUBLIC HEALTH 

In filariasis, the treatment course was successfully shortened to three 
days with hetrazan in dosages of 300 mg. three times daily. In the mass 
treatment of ancylostomiasis, tetrachloroethylene in a single dose of 3 to 
4 ml. before bedtime has been generally used with satisfactory therapeu- 
tic results. l-Bromo-2= naphthol was also reported to have been widely 
used with fewer side effects. 15 > 16 Kala-azar is generally treated with so- 
dium antimonial gluconate or other antimonial compounds. In the 
antimony-resistant cases, stilbamidine or the less toxic pentamidine is 
employed. 17 - 18 

The combined use of pumpkin seeds and Areca nuts were claimed in 
several reports to have been found highly effective in the treatment of 
taeniasis; they were said to paralyze the cephalic half and the caudal 
half, respectively, of the tapeworm. 19 - 20 > 21 

Also of interest is a report on the efficacy of hexachloroparaxylol 
(HPX) and hexachlorophene (G-ll) in the treatment of two human 
cases of Fasciolopsiasis Buski. 22 

2. Drugs for the Nervous system 

CorydaliS ambigua— Since the tranquilizing effect of Corydalis 
B was discovered in 1955-1957 a systematic study of its pharmacological 
properties has been carried out. The B substance is definitely effective 
as a tranquilizer, although not as active as hydergine, and it acts on 
different parts of the brain. Its analgesic and tranquilizing effects have 
been attributed to its levoglucose content. It also stimulates the secre- 
tion of ACTH. 

3. Cardiovascular Drugs 

a. Hypotensive drugs— Rauwolfia verticillata (grown in South 
China and Hainan Island), Veratrum schindleri, 23 Paconia moutan, 
and Chrysanthemum indicum L. have been found to have hypotensive 
activity. Clerodendron trichotomum T., traditionally used in China for 
headaches, rheumatism and other rheumatoid ailments, has been used 
in recent years to treat hypertension. The three active principles of 
this plant have been isolated for study of their hypotensive effects. A 
new alkaloid, named Liensinene, has been isolated from the green 
center part (embryo) of the seeds of Asiatic lotus Nelumbo nucifera G. 
and found to have hypotensive effects. 24 

4. Antibacterial Drugs 

Coptis chinesis F. is a Chinese traditional drug against 
dysentery. Berberine is one of the most active alkaloids studied. 25 Pai-ku, 
the seed of the plant Ginkgo biloba L., is a folk medicine for relieving 



PHARMACOLOGY 99 

chest congestions and treating tuberculosis. Its active principle Pai-ku 
hyrochloric acid has been found effective in arresting tuberculosis in 
animals. However, there have been no clinical reports confirming its 
effect against tuberculosis. 20 

5. Insecticides 

A number of new insecticides have been synthesized. For 
example, Titiwei is a new type of organic phosphate insecticide. It is 
many times more active than others against mosquitos, flies, fleas, bed 
bugs and cockroaches. 27 

6. Other Drugs 

Leomurus sibiricus L. is a popular postnatal herbal medi- 
cine. Several of its alkaloids have been isolated and studied. It has 
been proven to be an effective uterine stimulant. Glycyrrhiza glabra L. 
(licorice) was found to have cortisone-like properties, as one of its 
constituents, hypoglycyrrhic acid, showed action similar to that of 
desoxycorticosterone. There have been favorable clinical reports on 
the use of licorice in a variety of disorders, notably, Addison's disease. 28 
Mention should be made of a new effective molluscicidal agent, 
"SUHWA-203," against schistosomiasis japonica snails. 29 This new 
organic phosphorus insecticide was found by Chinese scientists to have 
an effective lethal action on the oncomelania snails. This may prove 
to be the most effective molluscicide against the resistant intermediate 
hosts, the oncomelania snails of schistosomiasis japonica, one of the 
most important and prevalent infectious diseases in China. 

7. Biologicals 

All the common antibiotics and biologicals currently used 
in the West have reached the production stage. The emphasis now is 
on prevention of communicable diseases. Considerable efforts have been 
made toward the development of vaccines for the treatment and pre- 
vention of Japanese B encephalitis, influenza, and trachoma, which are 
quite prevalent in China. Freeze-dried vaccines against measles, in- 
fluenza and yellow fever as well as sugar-coated pills for polio vaccine 
have been produced. 30 

In connection with biologicals, it should be mentioned that Chinese 
scientists were the first in the world to achieve total synthesis of a bio- 
logically active protein— crystalline bovine insulin— by chemical method 
1965. Two groups of Chinese chemists at the Institute of Biochemistry, 
Academia Sinica and Department of Chemistry, Peking University com- 
pleted this research project after four years of effort. It is a significant 



100 MEDICINE AND PUBLIC HEALTH 

contribution to basic research, signaling a beginning of an era of syn- 
thetic proteins. 31 

B. Pharmaceutical Industry 

China's pharmaceutical industry has kept pace with the de- 
velopment of all industries of the country. Following 20 years of per- 
severance and self-reliance, the pharmaceutical industry has changed 
from an industry reprocessing imported drugs to a completely self- 
sufficient manufacturing organization. Today, drug factories of various 
sizes are present in every province and autonomous region. Production 
has been steadily increasing in recent years, particularly for antibiotics, 
vaccines and antipyretics. Modern pharmaceutical techniques such as 
paper chromatography, electrophoresis, fluorometric analysis and 
stereochemistry have been employed in research and development. 
Quality control standards have been formulated for herbal drug pro- 
duction. Noteworthy is the fact that the processing and preparation of 
traditional drugs in the farm villages have been greatly advanced. With 
improved drug manufacturing techniques, liquid drugs are made more 
stable resulting in considerable improvement in the preparation of 
drugs for injection. 

Means of utilizing natural resources have also been emphasized. For 
example, substitutes have been found for gum arabic and cocoa beans. 
Studies are being conducted to improve ointment base and the manu- 
facture of contraceptives. New machinery and effective work methods 
have been developed. Antibiotic factories have been built in various re- 
gions of China. Today, equipment such as fermentation tanks, condi- 
tioning apparatus, measuring equipment, air compressors, ultra centri- 
fuges and titration equipment can be found of Chinese design and 
production. Factories built in recent years have used no foreign equip- 
ment. 

The growing production of antibiotics demanded increasing quanti- 
ties of lactose for fermentation, which was found to be expensive. Corn 
flour, which was inexpensive and plentiful, was first suggested as a sub- 
stitute in 1958 by Professor Chang Wei-shen of the Peking Biological 
Research Laboratory. Experiments with corn flour also led to the suc- 
cessful use of molasses and glucose which China produces in large 
quantities. 5 

China manufactures considerable quantities of a great variety of anti- 
biotics in current use; streptomycin, aureomycin, chloramphenicol, tet- 
racyclines, and the new semi-synthetic penicillins. The development of 
antibiotic production has contributed to the promotion of industrial 
microbiology. Notable achievement has been made, for example, in the 
fermentation of amino acids and vitamins, and in the microbial oxida- 



PHARMACOLOGY 101 

tion of steroids. Industrial biochemistry can be expected to become one 
of the important scientific developments for the national economy. It 
should be pointed out that in present-day China, the intensified use of 
antibiotics is not confined to medicine, but also is used in agriculture 
and stock raising. 

Since 1957, the price of penicillin has been markedly reduced with 
regularity. A wide range of antibiotics manufactured in China is pres- 
ently available in large quantities for export to other Asiatic countries, 
Europe and South America. 

C. Highlights on Practical Rural Medicinals 

Common folk medicinals in China have been found to be 
simple, economic and, within limits, effective. In answer to a govern- 
ment call to support agricultural expansion, these medicinals are most 
extensively used in agricultural areas. The more common remedies are 
listed below with their reported uses and content: 33 

1. Allium Tuberosum Roxb: The chiu-tsai is a perennial bulbous plant 
of the Liliaceae family. It has long, flat leaves and a hot taste. Both 
the root and the seed are used medicinally. It contains essential oils, 
sulfates, carbohydrates, as well as Vitamin C. It is nutritious, "stomach 
strengthening," and has antihemorrhagic effects. Its uses include (a) 
chronic alimentary illnesses, including stomach pain, nausea, vomiting, 
etc; (b) sweating and excessive urination, debility in women, leu- 
korrhea, cold in the lower extremities, etc.; (c) vomiting of blood, ex- 
cessive bleeding in females; (d) chronic dysentery with blood in the 
stool; and (e) hemorrhoids and metroptosis. 

2. Hen's egg: The shell is composed of calcium carbonate, calcium 
phosphate, as well as bits of animal colloidal matters and is an inex- 
pensive source of calcium for use in pediatric rickets, adult tuberculosis 
or for females during pregnancy. The egg yoke "oil" contains lecithin 
and vitamins A and D. It is a nutritious tonic and may be used as a 
substitute for cod-liver oil for tuberculosis patients. It is more effective 
than cod-liver oil and less obnoxious. From his research on the effects 
of lecithin in skin diseases, Professor Ma Wen-chao found that this 
product increases epithelial cell activity and resistance. 

3. Loaches: These eel-like fish are native to warm water bogs and 
ditches. The body is black and has no scales. The mucous secretion, 
used to treat acute inflammation of the skin, has also been used ex- 
tensively in cases of erysipelas, cankers, facial sores, otitis media, burns, 
arthritic and other pains, etc. It is painted on the affected area. 

4. Luffa Gourd: This is a type of vegetable grown all over the coun- 
try and is known as T'ien Szu'kua, T'ien-lo, or Shui-kus (in Kwang- 



102 MEDICINE AND PUBLIC HEALTH 

tung). It is a vine of the Cucurbitaceae family. Fresh luffa contains 
saponin, niter, and a great deal of mucus, xylose adipose, proteins, 
and Vitamins B and C. The pulp contains pentosan and cellulose. 
Luffa can be used as a diuretic, "blood cleaner" and detoxicant. It has 
an antitussive effect and is an expectorant. In present day experience 
it is given for colds, acute bronchitis, sore throats, chest pains, etc. 
Luffa lotion can also be used as a high grade cosmetic. There are al- 
ready commercial products sold in foreign countries that can be used 
on the face. Young people use it to beautify their faces. It is said to 
clear the skin and eradicate blemishes more effectively than other cos- 
metics. 

5. Sour Plum (Primus mume): This is the unripened plum fruit 
also known as "green plum". The Wu-mei or the Pai-mei are but the 
processed product of this plum. The plum belongs to the Roseceae 
family. It is cultivated all over China. The green fruit (raw) is used 
for medicinal purposes. The fruit contains succinic, citric, malic, tar- 
taric acids, edible alcohols, native lugistic acid, as well as certain ceryl 
alcohol-like substances. The sour plum is used as a cooling and' anti- 
febrile agent. It is an astringent, stops diarrhea, relieves pain, suppres- 
ses cough, vomiting and nausea. It is a germicide due to its acidic na- 
ture. Taken orally, it inhibits bacterial growth in the alimentary tract. 
It is also used for ascaris worms. (From more than ten years' clinical 
experience, the writer can attest to the anti-nausea and anti-emetic as 
well as the anti-diarrhea effect of the aqueous extract of this plum.) 
In modern experience it has been found effective in epidemic dysentery 
or fever of unknown origin in children. When used in acute gastritis 
and diarrhea, it is reported to be more effective than sulfa drugs. When 
used for typhoid and paratyphoid cases, it effects early eradication of 
fever and shortening the course of treatment. It was claimed to be an 
effective preventive for the cholera epidemic during the summer of 
1940 in suburbs of Soochow. 

6. Wax gourd (Benicasa hispada) : It is also known as the "pillow" 
or "east" melon. It is available in all parts of China and is of the 
Cucurbitaceae family (obtainable in Chinese communities, New York, 
Los Angeles and San Francisco) . The melon is large, cylindrical, re- 
sembling a pillow. When tender it is green and has fuzz covering the 
skin. When ripe, the surface will present a waxy and white powdery 
appearance. The flesh is light flavored and the center is hollow. The 
seed contains urease, adenal-histidine, trigonelline, etc. It is used for 
relieving inflammation, detoxication and healing of carbuncles and 
"internal pustulation." The peel of the gourd has a diuretic effect 
and is used in the treatment of nephretic edema. 



PHARMACOLOGY 103 

7. Corn Silk: Corn is a plant found in all rural areas. Its composition 
includes ergosterol, glucose, saponin, picrates, Vitamins C and K, and 
wood tar derivatives. According to Soviet research, oral administration 
of the silk preparation causes increases in biliary secretion and bilirubin 
concentration, accompanied by increased blood coagulinogenase, hasten- 
ing blood coagulation. It is also a diuretic. It is used in cases of chronic: 
hepatitis, bile duct illnesses, bile stagnation, biliary inflammation, stone 
formation, jaundice, chronic nephritic edema, urinary tract stone forma- 
tion, diabetes, hemorrhagic purpura, nose bleeds and hematuria. It may 
also be effective in hemorrhages due to lack of coagulinase 

(agglutinase) . 

8. Lotus: This plant is present in all parts of China, growing in shal- 
low ponds and boggy areas. The leaves, stalks and the flowers are 
named separately (in Chinese) . The pistils are called lien-shu, the 
seeds are commonly called lien-tzit. The root contains starch, asparagin, 
rafnnose; the leaves, stalk and pods, lotusate in small quantities. The 
flesh of the seed contains proteins, fats, carbohydrates, carotene, nucleo- 
flavin, and ascorbic acid and all parts of the plant contain tannic prod- 
ucts and have agglutinative effects. Small amounts of lotusin show car- 
diac stimulating and diuretic effects. The seeds are rich nutrients. Both 
the seeds and the young seedlings within serve as tranquilizers and 
diuretics. The root juice inhibits nausea and relieves drunkenness. The 
leaves, pods and stalks stop vomiting and bleeding. The seedlings 
"strengthen the gonads" and stop emissions. Thus it is prescribed for 
vomiting, nose bleeds, uterine bleeding, leukorrhea, chronic dysentery, 
diarrhea, nocturnal emissions, edema of pregnant women, and chronic 
nephritis. For chronic nephritis, it is more effective if used together 
with the leaves of Artemisia vulgaris and root of Amperata arundinacia. 
It is also used for hemorrhoids and anal fistulation. 

9. Mulberry Tree (Morns Alba) : This tree is cultivated all over 
China. The fruit is the mulberry and the leaves are used for silkworm 
feed. The white bark and the roots contain cetylic acid, certain sterols, 
as well as various glucosides. It also contains acid latex and volatile 
oils. The white bark has diuretic and antitussive activity. The shoot 
and leaves act as a blood pressure depressant. It is used for acute 
nephritis, heat stroke, edema of bronchial asthma, hypertension, 
rheumatic pains, etc. 

10. Earthworms (also known as ch'u-chan) : The traditional medical 
name is ti-lung. It is a vermes of the annulata species. It contains an 
antifebrile substance known as "antifebrile salt" (perichaeta) , which 
has been found to be a derivative of tyrosine. From dried earthworms, 
it is possible to extract an effective nitrogen-containing component, 



104 MEDICINE AND PUBLIC HEALTH 

which has the effect of dilating the bronchioles and affect the lung 
function of the rabbit (Chinese translation by Chao Ch'eng-ku, Chang 
Ch'ang-shao, 1937) . Its hypotensive effect is characterized in animal 
experimentation by mild, slow and sustained reduction of blood pres- 
sure. A detailed discussion on its hypotensive mechanism and compo- 
sition of material is reported in the Journal of the Lanchow Medical 
College, No. 4, 1959, by Chang P'ei-yen, et al. Uses include influenza 
and other acute fevers, high fevers in children, headaches, hypertension, 
cerebral strokes and palsy. 

11. Toads (also known as lai-ha-mo) : The following have been ex- 
tracted from the toad by Ch'en K'o-kuei: adrenalin, cholesterol, phel- 
lonic acid, cinobufofenine (also known as the amine of toad toxin) , 
cinobufotoxin, cinobufogonin. (Journal of Biology of Chemistry, Vol. 
87, No. 3, 1930, p. 741-53) . Cinobufogonin and cinobufotoxin are 
stimulants and have myocardiac and vago-stimulating effects. Toad 
secretion is a stimulant, an anti-inflammatory and antitoxic drug. It is 
used for treating carbuncles and sores. 

12. Turtles: They are native to lakes, rivers, ponds and bogs, espe- 
cially in Chekiang Province. The shell contains gelatins, fats and salts. 
These are used for nourishment and tonics, weeping carbuncles, fistula- 
tion, tuberculosis of the spine, knee joint, etc., and hasten calcification 
of pulmonary tuberculosis. 

13. Grasshoppers and Locusts: They are pests that attack rice 
plant leaves and are classified as Pachytylus, Orthoptera of the 
Arthropodas. They contain water, 22.6%; protein, 64.25%; fats, 2.33%; 
ashes, 3.3%; plus Vitamins A, B, etc. They are considered highly 
nourishing, tasty and can be used for subsidiary foodstuff and a condi- 
ment. Medicinally, they have the effect of calming the nerves and stop- 
ping coughs and they are used in whooping cough and tetanus. Grass- 
hoppers are said to be specific for cases of pertussis and asthma. 

Accelerated Growth of Natural Resources 

In order to meet the increasing need for traditional Chinese 
plant remedies, their cultivation has been greatly accelerated in recent 
years. Intensive campaigns have been launched to encourage farmers 
to grow medicinal plants (Fig. 1) . Response was enthusiastic, and, al- 
though planting and cultivation were accomplished solely by hand, 
results showed great increase in acreage cultivated and harvests sold 
over subsequent years (Fig. 2) . Important measures have been adopted 
by all departments concerned to implement the directive of the State 
Council for the development of traditional medicine. Schools and train- 
ing courses have been set up to teach the production of traditional 



PHARMACOLOGY 



105 




Figure 1. The Aster tartaricus cultivated by the Cadres' School of the Peking First 
Commerce Bureau. Chinese medicinal herbs are grown over large areas in the 
communes and brigades in the suburban counties of Peking (China Pictorial, Nov. 
1971) 

drugs (Fig. 3) . There have been projects all over the country to ac- 
celerate cultivation and to introduce new medicinal herbs. Also, a num- 
ber of medicinal plants reportedly have been successfully transplanted. 
For example, the famous ginseng, which was thought to be adaptable 
for cultivation only in the northeastern provinces, has been successfully 
planted in other areas, such as Shansi, Hopei, and Yunnan. 34 Carthamus 
tinctorius, Chrysanthemum incanum L. and Dioscorea japonica have 
been introduced to Kiangsu, Shanghai, Shantung, and Kuangtung. As 
they are produced locally, the needs for these plants in these provinces 
are met. There have also been large amounts of surplus to supply other 
regions where these plants are not grown. 

As to traditional remedies of animal origin, there have also been pro- 
grams of breeding medicinal animals with good results. For example, 
deer raising has developed rapidly in China the last few years (Fig. 4). 
A nation-wide survey program has also been carried out to locate all the 
soures of natural medicinal products in China. 32 



CONCLUSION 

To the Western scientist, Chinese medicine, with its long 
traditions of herbal medications, superstitions, and philosophy, has ap- 
peared somewhat strange, irrational and enigmatic, and, at best, em- 
pirical. Recently, as a result of an initial blend of Western and tradi- 
tional Chinese medical practice, some startling achievements such as 



106 



MEDICINE AND PUBLIC HEALTH 




Figure 2. The clinic staff of a production brigade in Changshu County, Kiangsu 
Province, process the medicinal herbs they have gathered (Medical Workers Sennng 
The People Wholeheartedly, Foreign Languages Press, Peking 1971) 



acupuncture anesthesia have been revealed. Two facts have been dem- 
onstrated: (1) That Western and Chinese traditional medical practices 
are not irreconciliable, and (2) that further potential usefulness of 
traditional Chinese medicine to medical science would require the use 
of Western scientific methods to analyze systematically and thoroughly 
and to identify and clarify causative factors and relationships. 

The challenge is clear. Initial headway gained by Western-trained 
scientists handicapped by limited equipment, experienced personnel 
and technological backup has demonstrated the great potential attaina- 
ble if full marshalling of adequate scientific resources were possible. 
The Chinese materia medica is a vast storehouse of complex, loosely 
structured, pharmacological information subject to scientific screening 
and verification. In the past, Western medicine has gained immeasura- 
bly from chance discovery and application of ancient Oriental medici- 
nals. Ephedrin (Ma Huang from China) and Rauwolfia serpentina 
(from India) are two classic examples of the application of Western sci- 
ence and technology to traditional herbal remedies. It is conceivable 
other herbal medicaments with equal potential to Western scientific 



PHARMACOLOGY 



107 




Figure 3. A health worker shows 
commune members the different 
medicinal plants and explains what 
they can do in treating and pre- 
venting diseases. (China Recon- 
structs, Nov. 1971) 




Figure 4. The Sika deer is a wild animal of great economic value. The knobs and 
collagen of its antlers are effective in promoting various functions of the human 
body, treating weakness of the heart muscle and hastening the healing of wounds. 
The antlers, after processing, are used for ulcers and swellings. The foetus, tendons, 
tail and viscera of the deer can be made into medicine. Deer raising has developed 
rapidly in China in the past few years. Herds of deer grazing on a P.L.A. farm. 
(China Pictorial, Nov. 1071) 



108 MEDICINE AND PUBLIC HEALTH 

and medical areas of interest exist. Such areas of interest may well in- 
clude the treatment of cancer, viral diesase, leukemia, and perhaps neu- 
romuscular ailments such as muscular dystrophy and poliomyelitis. A 
key program launched by Western scientific and medical professions to 
conduct an investigation into Chinese medical practices and medicines 
would be fraught with frustration and difficulties, but the payoff may 
well be worth the effort. 



PHARMACOLOGY 109 

REFERENCES 

1. Croizier, R. C: Traditional Medicine in Modern China. Harvard University Press, 
Cambridge, Mass., 1968. 

2. Dimond, E. G.: "Medicine in China." JAMA 218: 1552-1557, Dec. 6. 1971, p. 1556. 

3. "Medicine in China." Medical World News 13: 51-62, Jan. 14, 1971. 

4. Palos, S.: The Chinese Art of Healing. Herder and Herder, New York, 1971, p. 
201-203. 

5. Huard, P. and Wong, M.: Chinese Medicine. McGraw Hill Book Company, New 
York, Toronto, 1968, p. 184-188, p. 177-181. 

6. Said, H. M.: Medicine in China, Hamdard Academy, Karachi, 1965. 

7. Lee, T'ao. "Achievements in Materia Medica during the Ming Dynasty, (1368- 
1643)." Chinese Medical J., Volume 74, p. 177-191, 1956. 

8. Hon, T. C, et al.: "Achievements in the Fight Against Parasitic Diseases in 
China." Chinese Medical J., Volume 79, p. 493, 1959. 

9. Huang, T. Y., et al.: Chinese Medical J., Volume 82, p. 242, 1963. 

10. Hsu, J. H., et al.: Chinese Medical J., Volume 82, p. 92, 1963. 

11. "National Schistosomiasis Research Committee." Chinese Medical J., Volume 78. 
368, 378, 461, 1959. 

12. Chi, J. Y.: K'o-Hsueh T'ung-pao (Scientia), No. 3, 133, 1960. 

13. Chou, H. C, and Huang, M.: Chinese Medical J., Volume 80, p. 115, 1960. 

14. Chin, Y. C, et al., Sung, C. Y., and Hsu, Y. C: Chung-chi I-K'an (Intermediate 
Med. J.), No. 10, 16, 1959. 

15. Li, H. H.: Chinese Med. J., Volume 78, p. 148, 1959. 

16. Wang, C. Y.: Chinese Med. J., Volume 78, p. 257, 1959. 

17. Hou, T. C, Chung, H. L., Ho, L. Y., and Weng, H. C: Chinese Med. J., Volume 
79, p. 493, 1959. 

18. Wang, C. T. and Wu, C. C: Chinese Med. /., 78:55, 1959. 

19. Chiang, Y. L., et al.: Chinese J. of Parasitic if Infectious Diseases, 1:188, 1958. 

20. Hsieh, J. K.: Chinese J. Parasitic 6- Infectious Diseases, 1:190, 1958. 

21. Hsieh, H. M.: Chinese J. Parasitic & Infectious Diseases, 2:55, 1959. 

22. Chung, H. L., et al.: Chinese Med J., 84:533, 1965. 

23. Chin, K. C. and Hsu, P.: "Acta Physiol." Si?iica, 22:71. 1958: (Abstr., Chinese 
Med. J., 77:102, 1958). 

24. Chao, C. Y.: Chung-kuo K'o-hsueh, No. 11, 215-219, 1962. 

25. Wang, H. K.: Yao-hsueh Hsueh-pao, No. 11, 382-388. 1964. 

26. Fu, F. Y.: Hua-hsueh Hsueh-pao. No. 28, 52-56, 1962. 

27. K'o-hsueh Hua-pao (Science Pictorial) , Shanghai, No. 8, 284-285, Aug. 1965. 

28. Research Institute of Chinese Traditional Medicine, Yao-hsueh T'ung-pao 
(Pharmacological Bulletin) 7440, 1959. Appears as translation of "A Decade of 
Achievement in Research on Chinese Traditional Drugs," Office of Technical 
Services, OTS no. 60-31, 322. 

29. Shen, Y. P., et al.: "Experiment Studies on the Molluscacidal Effect of SUHW \- 
203 (S-TEPP) on the Oncomelania Snail." ACTA Parasitologica Sinica, 3: 1-6, 
Feb. 1966. 

30. Personal Communication. Victor Sidel, M.D., Director of Social Medicine, Monte- 
fiore Hospital, Bronx, N.Y., Dec. 1971. 

31. Kexue Tongbao (Science Bulletin), 17: No. 6, Mar. 30, 1966. 

32. Ed. Board, Chinese Society of Pharmacology, Yao-hsueh T'ung-pao (Pharma- 
cological Bulletin): "Celebrating the Fifteenth Anniversary of the Founding of 



110 MEDICINE AND PUBLIC HEALTH 

the Nation." JPRS 29, 270, 24 March 1965 (Article appears as No. 163 in JPRS 
Translations on Communist China's Science and Technology). 

33. Yeh, C. C: Chiang-su Chung-i (Kiangsu Chinese Traditional Medicine), Nanking. 
(Appears as English translation of serialized article: "Rural medical knowledge: 
Introduction to practical rural medicinals", in JPRS 38, 135) 

34. Chen, J. Y. P.: "Highlights of Pharmacology in Mainland China." Ann. Rev. 
Pharmacology, 2:11-16, 1962. 



II. HEALTH CARE 
ORGANIZATION AND 
ADMINISTRATION 



LAWS ON PUBLIC HEALTH 



Tao-tai Hsia, J.S.D. 



In view of the fact that the present revived interest in mat- 
ters Chinese is in large part prompted by the ping pong diplomacy of 
the Peking regime, it might be appropriate here to refer to a statement 
made by a member of the Chinese ping pong team while in the Wash- 
ington, D.C. area in April, 1972. When he was asked the reason for 
China's enthusiasm for ping pong, the player said that in the past 
China had been known as the "sick man of East Asia" (Tung-Ya ping- 
fu) and that the Communist leaders felt that one excellent way of 
improving the public health of the country was through recognition 
and encouragement of sports activities such as ping pong. 

Prior to coming to power in 1949 the Communist Chinese, under 
siege by the Nationalists, led an arduous existence in the remote, moun- 
tainous areas of the interior of China, where they witnessed and often 
fell victim to the ravages of disease flourishing there. They were made 
personally and acutely aware of the obstacles presented by lack of medi- 
cine and medical facilities and personnel. The constitutional documents 
issued by the Communist Chinese in the pre-1949 period reflect their 
desire to alleviate the physical suffering of the mass of China's poor and 
to lay a groundwork for the recovery of "East Asia's sick man" by re- 
storing and guarding the health of its citizenry. The Administrative 
Program of the Shensi-Kansu-Ninghsia Border Region, approved by the 
Political Bureau of the Chinese Communist Party on May 1, 1941, sets 
forth in its Article 15 the Party's intention "to promote public health 
administration, to increase the supply of medicine and medical equip- 
ment, to attract medical personnel in order to reduce the sickness of the 
people, and at the same time to render assistance to disaster victims and 
refugees from outside (the border region). 1 Article 11 of the Adminis- 
trative Program of the Shansi-Chahar-Hopei Border Region, promul- 

113 



1 14 MEDICINE AND PUBLIC HEALTH 

gated on August 13, 1940, and passed on January 20, 1943, by the First 
Consultative Council of the Border Region as the Administrative Pro- 
gram of the Border Region, similarly indicates the aspiration "to pro- 
mote the hygiene and sanitation movement and to improve public 
health in order to prevent the disaster caused by disease". 2 The people's 
right to freedom from ill health is affirmed in item 3 of the section 
"Rights of the People" in the Constitutional Principles of the Shensi- 
Kansu-Ninghsia Border Region, which was passed by the Third Consul- 
tative Council of that border region on April 23, 1946. In support of this 
right, the document declares that "public health education and the sup- 
ply of medicine, medical services, and medical equipment shall be de- 
veloped". 3 

The determination to improve the health of the Chinese populace 
through implementation of vigorous public health programs was reaf- 
firmed in the constitutional documents issued upon and after institu- 
tion of the People's Republic of China on October 1, 1949. The 
Common Program of the Chinese People's Political Consultative Con- 
ference, adopted on September 29, 1949, stated in its Article 48: 

Article 48. National physical culture shall be promoted. Public health and 
medical work shall be expanded and attention shall be paid to the pro- 
tection of the health of mothers, infants and children. 4 

Article 93 of the Constitution of the People's Republic of China, which 
was adopted on September 20, 1954, and has remained in force at least 
formally up to the present, similarly provides; 

Article 93. Working people in the People's Republic of China have the 
right to material assistance in old age, and in case of illness or disability. 
To guarantee enjoyment of this right, the state provides social insurance, 
social assistance and public health services and gradually expands these 
facilities. 5 

In line with the policy relating to public health set forth in these 
constitutional documents, the People's Republic of China has enacted a 
large number of public health laws, regulations, directives, decisions, 
etc. What the regime considers the most important of these legal norms 
on public health have been published in the two major official statutory 
compilations of the Peking Government, Chung yang jen min cheng fu 
fa ling hui pien (Collections of Laws and Decrees of the Central Peo- 
ple's Government) and Chung-hua jen min kung ho kuo fa kuei hui 
pien (Collection of Laws and Regulations of the People's Republic of 
China). The first of these collections comprises five volumes covering 
the period from September 1949 to September 1954 and published 
from 1952 to 1955; the second consists of 13 volumes covering the pe- 
riod from September 1954 to December 1963 and published from 1956 



LAWS ON PUBLIC HEALTH 115 

to 1964. To our knowledge, no new number has been added to the sec- 
ond series since 1964. Further, there are no public health documents in- 
cluded in the second series after Volume 11, which covers the period 
January to June 1960. 

For discussion in this article, we have selected from these two statu- 
tory compilations 54 documents relating to public health. We have ex- 
cluded from consideration only a very few of the documents included 
in these compilations under the rubric "public health," the basis for ex- 
clusion being the fact that these few documents dealt almost exclusively 
with physical culture. The 54 documents which we discuss appear to us 
to have been generally neglected in the study of public health in the 
People's Republic of China. In part the neglect is due to the scarcity of 
English translations of these documents; in part, however, it is due to 
the non-lawyer's reluctance to use legal materials from fear that they 
will be overly technical for his purposes. Our major aim in presenting 
this article is exposing as a misconception the attitude that Communist 
Chinese legal materials dealing with public health are of use princi- 
pally, if not exclusively, to scholars of Chinese law. We hope to suggest 
here that study of legal documents has for the non-legal scholar certain 
advantages vis-a-vis the use of other types of research materials on 
public health in Communist China. 

The American scholar of public health, with his general knowledge 
of the nature of Western legal materials, might expect to find in legal 
documents on Communist Chinese public health detailed descriptions 
in obscure, technical language of the structure and functions of public 
health organs on mainland China, elaborate presentations of the budg- 
etary programs of these organs, more or less full statements of the 
public health services theoretically available to the citizen, etc. Know- 
ing the universal gap between formal legal provisions and actual imple- 
mentation of these principles, he might feel that he had best examine 
available materials relating to the actualities of public health in the 
People's Republic of China. General acquaintance with or a suspicion 
of the inferior role law plays in any Communist state might tend to 
confirm him in this latter view. 

A reading of even a few legal documents relating to public health in 
the People's Republic of China (hereafter, PRC) will both disappoint 
and surprise our hypothetical American scholar of public health. Of the 
structure and functions, funding, scope of available services, etc., he 
will find only unsystematic and sketchy indications, thus bringing him 
to an awareness that partial information from many different types of 
Communist Chinese materials, among them the legal, must be pieced 
together before one gets a glimmering of the total public health picture 
on the Chinese mainland. Although sometimes more systematic struc- 



116 MEDICINE AND PUBLIC HEALTH 

tural and functional descriptions are found in legal documents than in 
other types of materials, the Communist Chinese leaders have far from 
felt constrained to precede the creation of an institution or program 
with an elaborate statement in black and white of its structure and 
functions, purposes,, aims, funding, etc. 

The American public health scholar, disappointed in his expectation 
of systematic description, perhaps will be pleasantly surprised by the 
non-technical nature of Communist Chinese legal documents. One of 
the chief explicit functions of the law in the PRC is education of the 
citizenry. To fulfill its educative role, the Peking leaders insist, the law 
must be readily intelligible to the cadres, often not highly educated, 
and the masses who are responsible for its implementation. A funda- 
mental principle of the drafting of Communist Chinese legal docu- 
ments, therefore, is that they be written in simple, non-technical lan- 
guage and style. These popularly oriented legal documents often are 
used as study materials in the waves of mass nature campaigns that reg- 
ularly sweep over the mainland. Their tone typically is hortatory rather 
than cooly analytical or descriptive. They are replete with ideological 
formulations inserted as sincere justification for the principles they 
state and as propagandistic instruction for their readers. 

The Communist Chinese leaders do not bring about the enactment 
of a law as a necessary and routine preliminary step in implementation 
of a particular policy. Typically, they have reduced a policy to a writ- 
ten statutory statement only when they have been most certain of its 
central importance and have felt most assured of its continued validity. 
Legal documents thus constitute a relatively succinct statement of the 
basic and enduring concerns of the regime. Further, legal documents 
issued by the central government generally are applicable to all of 
China, a characteristic which further confirms their basic nature and 
contributes to their lasting value. 

With this background information on law in the PRC in mind, we 
wish to state the basic themes contained in the 54 legal documents con- 
sidered here, thus removing the necessity of repeating them at every 
occurrence. The frequency with which these themes recur in documents 
issued during a ten-year period well illustrate the consistency of the 
Communist Chinese in their policy and approach to public health 
problems. These themes are: 

1) Prevention, rather than treatment, is to be the primary empha- 
sis of all public health work. 

2) More and more public health services are to be extended, 
within the limitations of the possible, to the Chinese masses, most es- 
pecially to the poor, the geographically isolated, and women and chil- 



LAWS ON PUBLIC HEALTH 117 

dren; if the people cannot come to receive these services, the services 
will be taken to them. 

3) All possible human resources are to be drawn into public 
health work, particularly the People's Liberation Army, traditional 
Chinese doctors, and women cadres; such training as is necessary to 
their playing the intended role in public health work is to be provided. 

4) There must be systematic gathering, synthesis, and analysis of 
information relative to the public health problems and to the human 
and natural resources available for combatting them. 

5) A rational, scientific, and thorough approach toward public 
health problems is to be instilled in the cadres and in the masses to 
combat ignorance and superstition and to eradicate the haphazard, 
inefficient, and uncommitted approach of previous regimes towards 
these problems. 

6) Exacting standards are to be set for all products, personnel, fa- 
cilities, and services having bearing on public health. 

7) Purposeful, informed research must be carried out relative to 
the various aspects of public health work, most particularly relative to 
the validity of traditional Chinese medicine. 

For convenience of discussion, the 54 legal documents on public 
health in the PRC have been grouped into the following four catego- 
ries: 1) prevention and treatment; 2) medical and public health per- 
sonnel and facilities; 3) Chinese medicinal materials. Within each cate- 
gory, the documents are arranged chronologically. One document which 
does not fall neatly into any of the above categories is discussed briefly 
at the end under the heading "Miscellaneous." 

I. Prevention and treatment 

1. Directive of the Ministry of Public Health and the Public 
Health Department of the People's Revolutionary Military Council on 
promoting a plague prevention program for military personnel and 
civilians in the spring. February 10, 1950 (I.I: 631-633) . 6 

The first document on public health included in the first statutory 
compilation, this directive elaborates upon most of the basic themes of 
public health work in the PRC set forth in the initial part of this paper 
and thus can be considered a basic source. Its first section gives some 
idea of the enormity of the public health problems faced by the regime 
in its early days, laying much of the blame for these problems at the 
door of the reactionaries. A spirit of confidence in the face of these 
problems characterizes the tone of this document. "Responsible person- 
nel at the hsien (county) level and above" are charged with many re- 
sponsibilities with regard to educative propaganda, administration, and 



118 MEDICINE AND PUBLIC HEALTH 

actual implementation of plague prevention programs. As the title indi- 
cates, concern over the effect of health on the fighting capacity of its 
soldiery was one motivational source behind the public health work of 
the PRC. 

2. Joint directive of the Ministry of Public Health and the Public 
Health Department of the People's Revolutionary Military Council 
pertaining to the prevention of cholera, April 22, 1950. (LI: 638-639). 

This directive, again jointly issued, is the first of several presented 
here dealing with combatting a specific disease. After indicating the 
areas usually most severely affected by the spread of cholera, the docu- 
ment delivers a scathing attack upon the Nationalist government for its 
failure to cope with the disease. The remainder of the document is de- 
voted to the statement of various concrete steps which can and must be 
taken to eliminate cholera, among them the inoculation of 50% of the 
civilian population and 100% of the troops by mid-June in areas where 
there is a strong possibility of the outbreak of an epidemic. The pro- 
posal is to have a timely combined inoculation for cholera, typhoid, 
and typhus. There is a strong emphasis upon accurate and instanta- 
neous reporting of cases of cholera as a primary means of controlling 
the spread of the disease. Special attention is to be devoted to areas 
where the masses are the poorest and sanitary conditions are worst, such 
as the boat-people communities and the slums in large cities; this ap- 
proach is both scientifically valid and ideologically appealing to the Pe- 
king government. 

3. Directive of the Government Administration Council regarding 
the launching of the autumn campaign for smallpox vaccination, pro- 
mulgated October 12, 1950 (1.1: 640-641). 

With characteristic Communist Chinese ambitiousness and determi- 
nation, this directive sets forth the goal of completely wiping out small- 
pox in China within a specified time through universal free vaccina- 
tion and indicates something of the manner and spirit in which this 
vaccination program is to be carried out. The seriousness of the re- 
gime's intention is evident in their insistence that traditional Chinese 
doctors be trained to administer vaccination and that, in places where 
no public health organs exist as yet, the cultural and educational or- 
gans must organize the vaccination program. The policy of "each one 
teach one" finds an early expression in the requirement that trained 
personnel "go to all hsien and all villages and further train village edu- 
cational and cultural workers and women cadres" to carry out the pro- 
gram. 

4. Provisional measures governing smallpox vaccination. Promul- 
gated October 12, 1950 (1.1: 642-643). 



LAWS ON PUBLIC HEALTH 119 

Starting with the provision that "all inhabitants of the PRC regard- 
less of nationality shall be vaccinated for smallpox," these provi- 
sional measures give much more detailed treatment than is customary 
in Chinese legal documents of the specific policies and features of the 
vaccination program. Its Article 6 contains the provision that those 
who refuse to be vaccinated even after reasonable efforts have been 
made to persuade them to submit to vaccination may be forced to re- 
ceive the vaccination, a provision that is understandable if one takes 
into account the superstitiousness of many Chinese and their lack of 
knowledge of and fear of modern medical techniques. Trained medical 
personnel are denied the right to refuse an assignment in the public 
vaccination program, even if they are privately employed. Various un- 
sanitary practices, such as taking serum from human sores, are prohib- 
ited. 

5. Directive of the Government Administration Council regarding 
intensification of the patriotic public health campaign in 1953. Decem- 
ber 31, 1952(1.3: 211-212). 

At the time this directive was issued, the Peking regime was irately 
charging the United States with using germ warfare as one of its tactics 
in the Korean war. Whether or not the charges were justified or 
whether or not the Communist Chinese themselves were convinced of 
the truthfulness of their charges is not known. What is certain is that in 
this directive the mainland authorities exploited the putative danger 
from germ warfare to spur the population on to more strenuous efforts 
in public health work. Exploitation of possible danger is a tactic which 
the Communist Chinese frequently use to give impetus to various 
campaigns and to keep the populace in a state of heightened tension. 
Even today, the slogan "be prepared for war, be prepared for famine" 
is frequently used. After calling for the extra vigilance necessitated by 
germ warfare, the directive details many concrete steps which can be 
taken to improve sanitation and hygiene. Another characteristically 
Communist Chinese tactic in mass campaigns appears in this directive's 
instruction that those who make real achievements in public health 
work are to be given wide publicity and those who lag behind are to 
be publicly censured. A blitzkrieg public health campaign was to be 
scheduled for the spring of 1953, a campaign for which a special Patri- 
otic Public Health Campaign Committee was to lay plans. The name of 
this campaign and committee makes obvious the Communist Chinese 
equation of good public health practices to patriotism. 

6. Directive of the Ministry of Higher Education, the Ministy of Ed- 
ucation, the Ministry of Public Health, and the Physical Culture and 
Sports Commission regarding the introduction of health protection pro- 
grams in the schools. June 17, 1954 (1.5: 211-213). 



120 MEDICINE AND PUBLIC HEALTH 

Although commending the schools for the progress which they have 
made since promulgation of a decision regarding the improvement of 
health conditions of students of schools of various levels, this directive 
takes the schools to task for emphasizing medical treatment to the ne- 
glect of disease prevention work. To correct this defect, the directive 
calls for the strengthening of concrete guidance to the schools in their 
health preservation programs from the educational, public health, and 
sports organs of various levels. To underwrite better implementation of 
the regime's policy, the directive specifies that expenses for school doc- 
tor's offices and health rooms and for health preservation work in gen- 
eral shall be included in the regular budget. The regime's readiness to 
encroach upon the "free time" of the Communist Chinese citizen in pur- 
suit of its aims is evident in its instruction that elementary school 
teachers having responsibility for health preservation work shall use 
their vacation or afterwork hours to gain public health training. 

7. Measures governing the control of communicable diseases. Ap- 
proved June 1, 1955; issued July 5, 1955 (II.2: 823-827). 

The first document from the second statutory compilation considered 
under the rubric "prevention and treatment," these measures are aimed 
at the control of two categories of communicable diseases, the first cate- 
gory comprising bubonic plague, cholera, and smallpox, and the second 
category consisting of 18 diseases, including meningitis, typhoid, and 
scarlet fever. The people's councils (governments) of various levels are 
charged with the responsibility of seeing to it that the public health or- 
gans carry out fully the regime's policies. Time limits are set for the 
reporting of the occurrence of any of the communicable diseases cov- 
ered in these measures. Relatively detailed provisions governing quar- 
antine, treatment of afflicted persons, and preventive education of those 
likely to be exposed to the afflicted are set forth. 

8. Directive of the Ministry of Education, the Physical Culture and 
Sports Commission, and the Ministry of Public Health on the improve- 
ment of physical culture activities in middle and primary schools. Au- 
gust, 1955 (II.2: 828-833). 

In addition to urging the strengthening of programs of sports activi- 
ties, this directive charges the school doctor with the responsibility of 
seeing to it that sports activities shall be conducted with due considera- 
tion for the student's health. 

9. Directive of the Ministry of Public Health on strengthening pub- 
licity on hygiene, June 1, 1956 (II. 3: 565-567). 

Holding forth the goal of catching up with the public health level of 
the more advanced nations in the world, this directive indicates that, in 
view of the increasing literacy of the Chinese population, it is timely to 



LAWS ON PUBLIC HEALTH 121 

launch a campaign designed to increase knowledge and awareness of 
proper hygiene. Some of the mechanics of carrying out such a mass cam- 
paign are outlined. 

10. Joint directive of the Ministry of Public Health and the All- 
China Federation of Trade Unions regarding the strengthening of hy- 
giene and medical care activities in industrial and mining enterprises, 
September 13, 1956 (II.4: 473-478). 

This joint directive was issued in response to the regime's having 
taken note of the rise of absenteeism on account of illness among in- 
dustrial and mining workers. It directs public health medical treatment 
units and trade union organizations of all levels to strengthen the treat- 
ment and prevention of disease in all industrial and mining areas, espe- 
cially through drawing up plans for the elimination of various kinds of 
occupational diseases within seven to 12 years and taking active steps to 
prevent such diseases as tuberculosis, malaria, arthritis, and various gas- 
trointestinal disorders. These units and organizations also are advised 
to improve the working conditions of industrial and mining workers 
and to implement the policy of "prevention is primary" by conducting 
mass campaigns designed to educate the workers in good sanitation and 
hygiene. Workers in factories and mines are to receive periodic physical 
examinations, as are those employed in food supply units, eating facili- 
ties, and nurseries. A humane touch is added in the instruction that 
hospitalized patients, especially those without families, are to be visited 
and cheered up. 

11. Directive of the Ministry of Public Health and the Ministry of 
Agriculture on the prevention and treatment of osteohypertrophy, Janu- 
ary 12, 1957 (II.5: 325-330). 

According to this directive, osteohypertrophy is endemic to northeast- 
ern and northwestern China and Inner Mongolia. It was found, for ex- 
ample, that 1983 or almost 71% of the 2,400 elementary school students 
in one county in Chilin were afflicted with this disease. Not entirely 
certain as to the cause of osteohypertrophy, the Communist Chinese 
here set forth a multi-pronged course of action based upon three the- 
ories of its possible causes, the theories being that it is caused by germs 
found in food, particularly grains; that it is caused by polluted water; 
and that it is caused by malnutrition. Three localities in Chilin, Hei- 
lungkiang, and Shensi are selected for experimental action and study 
which subsequently will form a basis for a more widespread attack 
upon osteohypertrophy. 

12. Provisions regarding the scope of occupational diseases and the 
procedure for dealing with those who are afflicted with these diseases, 
Issued February 28, 1957 (II.5: 331-333). 



122 MEDICINE AND PUBLIC HEALTH 

In keeping with the regime's ideological and political commitment to 
the working class, the Communist Chinese here outline a program for 
the identification, meticulous study, and treatment of 14 categories of 
occupational diseases. It is stated that workers afflicted with occupa- 
tional diseases are to be given insurance benefits and that they are to be 
transferred to another job or area if such action would be beneficial to 
their health. 

13. Notification by the Ministry of Public Health on the protection 
of women and minors performing labor in rural areas, the strengthen- 
ing of publicity on health information among women and children, 
and the faithful carrying out of health work in nurseries, April 2, 1957 
(II.5: 333-335). 

The Communist Chinese have always paid special attention to women 
and youth as two possibly disaffected groups likely to give support to 
the Party if properly wooed. That the "liberated" Chinese woman is an 
essential part of the work force in post- 1949 China gives the regime 
even more incentive to take steps to improve her life. This notification 
calls on a number of organizations in China to give widespread public- 
ity to information relating to the protection of women and children, 
birth control, and child care. To ease the mind of the potentially wor- 
ried mother who leaves her child behind in a nursery while she works, 
the notification calls for strict control of nursery personnel and close at- 
tention to sanitation and hygiene in the nursery. 

14. Directive of the State Council regarding eradication of schisto- 
somiasis, April 20, 1957 (II.5: 341-350). 

Schistosomiasis, this directive points out, is a most serious disease 
whose victims in China number more than 10 million. As in the case of 
osteohypertrophy, concerted efforts are to be made to eradicate schisto- 
somiasis. 

15. Notification by the Ministry of Public Health regarding the issu- 
ance of a national plan for the prevention and treatment of leprosy, Oc- 
tober 28, 1957 (II.6: 554-566). 

This notification gives a description of special facilities established 
in China for the treatment of leprosy and figures on the numbers of 
those afflicted with, treated for, and cured of leprosy. Applying to lep- 
rosy the regime's basic policy that "prevention is primary," this docu- 
ment outlines several fundamental steps which can be carried out to 
control leprosy, including the establishment of leprosy prevention insti- 
tutes and stations, improvement of the quality of personnel dealing 
with leprosy, and the strengthening of scientific research on leprosy. 

16. Border quarantine regulations of the People's Republic of China, 
passed and promulgated December 23, 1957 (II. 6: 566-567). 



LAWS ON PUBLIC HEALTH 123 

The border quarantine regulations of the PRC are aimed especially 
at preventing exit and entry of persons suffering from such epidemic 
diseases as bubonic plague, cholera, yellow fever, smallpox, typhoid, etc. 
The various articles of this document deal with the establishment of 
quarantine stations, inspection of the person and property of travellers, 
an epidemic intelligence and reporting system, the imposition of quar- 
antine, and the punishment of violators. 

17. Directive of the Central Committee of the Communist Party of 
China and the State Council concerning eradication of the four pests 
and adoption of hygiene practices, February 12, 1958 (II. 7: 453-459). 

Issued during the Great Leap Forward period, which was character- 
ized by a frenetic assault on all limitations of time, material, physical 
strength, etc., this directive in effect declares war on sparrows, rats, flies, 
and mosquitoes. Target dates for the total elimination of these four 
pests are set for various localities. 

18. Rules governing the application of the border quarantine regula- 
tions of the People's Republic of China, approved December 20, 1957; 
issued March 25, 1958 (II.7: 460-492). 

This lengthy supplementary document consists of ten chapters: 1) 
general provisions, including definition of terms; 2) intelligence and 
reporting; 3) quarantine organs; 4) quarantine in seaports; 5) quaran- 
tine in airports; 6) quarantine at a land border; 7) procedures for han- 
dling cases; 8) handling of quarantined infectious diseases; 9) quaran- 
tine fees; and 10) supplementary provisions. 

19. Notification by the Ministry of Public Health regarding the con- 
scientious launching of public health work among the workers in me- 
dium- and small-scale enterprises, July 7, 1958 (II. 8: 262-264). 

Medium- and small-scale enterprises typically have fewer resources, 
facilities, and programs for carrying out public health work. In recogni- 
tion of this phenomenon, the PRC Ministry of Public Health here sin- 
gles such enterprises out for attention. Public health organs are directed 
to do special studies of the public health problems of these enterprises. 
Improvement of working conditions with a view toward controlling oc- 
cupational disease is the focal point of policy with regard to medium- 
and small-scale enterprises. The notification also evidences a concern 
for those living in areas adjacent to these enterprises, for it urges the 
avoidance of sound, water, and atmospheric pollution. 

20. Notification by the Ministry of Public Health regarding the issu- 
ance of a national plan (1958-1962) for the prevention and treatment 
of mental illness, September 15, 1958 (II.8: 266-272). 

Although boasting of their achievements in work with mental illness, 
the Communist Chinese here are determined to rectify defects in this 



124 MEDICINE AND PUBLIC HEALTH 

work, such as too great a reliance upon chemotherapy, neglect of treat- 
ment of outpatients, giving short shrift to the traditional Chinese treat- 
ment for mental illness, etc. They define the characteristics of the 
working style of an ideal mental health worker and outline the basic 
principles of treatment of the mentally ill, including physical therapy 
which combines both Chinese and Western methods; labor, most typic- 
ally of the physical type; systematically organized athletic, cultural, and 
entertainment activities; and education. This document gives evidence 
of the shift of emphasis from having traditional Chinese doctors learn 
from Western medicine to having Western style doctors study and learn 
from traditional Chinese medicine. 

21. Notification by the Ministry of Public Health regarding the issu- 
ance of a national plan for the prevention and treatment of trachoma, 
September 27, 1958 (II.8: 272-282). 

Noting that it is estimated that as much as 50% of the Chinese popu- 
lation suffers from trachoma, this notification sets the goal of wiping 
out this serious disease within ten years. As is usual when a goal is set, 
the basic methods of attack are outlined. Again, there is a call for study 
of traditional Chinese ways of treatment and for the synthesis of these 
ways with the Western approach. 

22. Notification by the Ministry of Public Health regarding the thor- 
ough implementation of the emergency directive of the Central Com- 
mittee of the Communist Party of China and the State Council con- 
cerning the launching of the anti-disaster struggle, September 1, 1949 
(11.10: 408-410). 

Issued at a time of crisis in China precipitated in part by natural ca- 
lamities, this notification backs up a crucially important directive is- 
sued previously by the high level party and state officials (such joint is- 
suance is a reliable indication that the subject matter of the document 
is considered highly important). The notification addresses itself to the 
handling of physical maladies associated with natural disasters. 

23. Regulations governing the safety of drinking water, issued Sep- 
tember 17, 1959; effective November 1, 1959 (11.10: 410-416). 

The three parts of these regulations are devoted to standards of water 
purity, choice of acceptable water sources, and protection of the purity 
of these sources. Strong emphasis is placed upon prevention of contami- 
nation of sources of drinking water. 

24. Directive of the Central Patriotic Public Health Campaign Com- 
mittee and the Ministry of Public Health regarding the energetic pro- 
motion of the winter and spring work for the prevention and treatment 
of infectious diseases, November 21, 1959 (11.10: 417-419). 

Proof of the longevity of the Patriotic Public Health Committee, 



LAWS ON PUBLIC HEALTH 125 

mentioned earlier, this directive calls for yet another energetic cam- 
paign to educate the people in the avoidance and handling of cases of 
infectious disease. 

25. Notification by the Central Patriotic Public Health Campaign 
Committee and the Ministry of Public Health on strengthening preven- 
tive measures in connection with major summer and autumn diseases, 
May 11, 1960(11.11: 215-219). 

Praising the success of the campaign announced in the immediately 
preceding document, this notification calls for a campaign combining 
the themes of prevention of infectious diseases, eradication of the four 
pests, and close attention to hygiene. 

II. Medical and Public Health Facilities and Personnel 

26. Directive of the Ministry of Public Health regarding the 
1950 medical administration work, April 14, 1950 (1.1: 634-637) . 

Set forth in this directive are the basic policies which guided the re- 
gime in its earliest efforts toward establishing a pervasive network of 
public health facilities on the Chinese mainland, starting from the res- 
toration of public health organs previously operated by the Nationalists 
and then establishing as many new organs as feasible given the limita- 
tions of available funds and personnel. Preparatory to the drawing up 
of a national public health plan, all areas are enjoined to submit con- 
crete data about existing facilities and personnel, and plans for future 
work in the area of public health. 

The directive carries instructions aiming at a fundamental reorienta- 
tion of public health work. Not only is prevention, rather than treat- 
ment, to be primary, but also all personnel must adopt the viewpoint of 
serving the people. The notion that medical work is another form of 
commercial activity is condemned, as is the attitude that the carrying 
out of medical work is dependent upon a high level of sophistication in 
available technology. 

Although in this document the Chinese Communists do not insist 
upon abolition of the private sphere in medical practice, they do indi- 
cate that private public health and medical personnel "should be en- 
couraged" to join semi-cooperative, united, or joint hospitals or joint 
clinics. 

One of the central tasks is said to be the organization and further 
training of doctors practicing traditional Chinese medicine with a view 
toward synthesizing the best of traditional style and Western style med- 
icine. The intention to organize training schools for practitioners of 
traditional medicine is announced along with an outline of a curricu- 
lum for them which would introduce the traditional doctor to the basic 
principles and practices of Western medicine. 



126 MEDICINE AND PUBLIC HEALTH 

The goal of the imposition of modern management techniques upon 
and control of hospitals and clinics, both public and private, is an- 
nounced. These institutions in both the public and private sphere are 
to follow standardized fee schedules. The private hospital or clinic is 
warned that they also must shoulder part of the responsibility for public 
health work and that they must concern themselves with service and 
not just with money. 

27. Provisional regulations governing the management of hospitals 
and clinics, approved January 19, 1951; promulgated March 15, 1951 
(1.2: 489-491). 

Applicable to all private and public hospitals and clinics, with the 
exception of clinics operated by Chinese herb doctors, these provisional 
regulations, open with the setting forth of certain modest standards 
which a medical facility must meet in order to call itself a hospital or a 
clinic. A hospital, for example, is required to have a minimum of only 
ten beds, two doctors, and three nurses or assistant nurses, and one 
pharmacist. The medical treatment and public health activities of all 
hospitals and clinics are to be under the supervision of the public health 
organs of the local people's government. The local people's government 
is empowered to issue essential licenses to privately operated hospitals 
and clinics and to pass judgment on their schedules of fees. The mak- 
ing of false claims in advertising is strictly prohibited. In Chapter 3 of 
this document, headed "Activities," hospitals and clinics are told that 
they must engage in work aimed at the prevention of disease, that they 
have certain responsibilities in the event of the outbreak of an epi- 
demic, and that they cannot without proper reason refuse treatment to 
any person. Certain basic ethical requirements related to the practice of 
medicine are established. Chapter 4 defines a graded scale of punish- 
ments for violation of these regulations. 

28. Decision of the Ministry of Public Health and the Ministry of 
Education on the development of public health education and the 
training of public health workers at all levels, approved and promul- 
gated April 4, 1951 (1.2: 492-493). 

According to the provisions of this decision, public health education 
in the PRC is to be divided into the high, intermediate, and basic lev- 
els, all of which are required to implement the government's policy of 
giving priority to preventive measures and of carrying out public health 
work principally for the benefit of the laboring people. 

The existing system of high level medical education is to be re- 
formed. Certain high level medical schools shall be authorized to con- 
duct experimental programs in specialized medical education involving 
reduction of the number of years of study. (It should be noted that ad- 
mission to these high level medical schools demands only a high school 



LAWS ON PUBLIC HEALTH 127 

diploma and that the years of study given here refer to the number of 
years of study beyond high school.) In these experimental programs, 
students in the following four departments shall follow a five year 
course: departments of internal medicine, surgery, pediatrics, and ob- 
stetrics. Those specializing in dentistry, eye, ear, nose, and throat, 
and public health shall have a four year course of study. Students in 
any of the five departments of pharmacology also shall study four years. 

At the high level, there also may be a special two-year course of study, 
roughly equivalent to a junior college course, in medicine, pharmacol- 
ogy, and public health engineering. Completion of the special two year 
course must be followed by a training period of at least six months. 

Admission to intermediate level public health schools requires only a 
junior high diploma. Education at this level includes schools for med- 
ics, nurses, and maternity aides. Medics shall follow a two year course, 
followed by six months of practical training; the same requirement ap- 
plies to nurses and maternity aides. A selected number of such schools, 
with the approval of the Ministry of Public Health, may set up special 
courses for the training of teachers to staff intermediate level schools; 
admission to this teacher training course requires graduation from high 
school. The teacher training course normally will require two years of 
study, followed by three to six months of practical training; however, 
in the case of those who already are graduates of schools of nursing or 
schools for maternity aides and who have had two years of practical ex- 
perience, the course may be shortened to one year. 

Intermediate level education for other types of public health techni- 
cians may encompass periods of from six months to two years, depend- 
ing on the nature of the course. 

Basic level public health education includes the training of personnel 
to staff public health organs at the hsiang (village) and ts'un (hamlet) 
levels, personnel skilled in the care of women and children, and nursing 
aides. Education for hsiang and ts'un public health personnel shall ex- 
tend to six months, while lasting only three months for the other two 
categories of persons. 

The enrollment of existing medical and public health schools shall 
be systematically increased, and new schools shall be established. 

The Ministry of Education and the Ministry of Public Health shall 
jointly define minimum standards for the curricula and textbook con- 
tent of medical and public health schools. High level medical schools 
shall be governed by the decision of the Government Administration 
Council regarding the guidance relationships of schools of higher learn- 
ing. The routine administration, size of faculty, fiscal management, 
physical facilities, and curricula of intermediate level schools shall be 
under the supervision of public health organs at the provincial level; 



128 MEDICINE AND PUBLIC HEALTH 

however, the educational policy, system, and relations of such schools 
will be led by the government's education organs. Basic level public 
health education shall be led by public health administrate organs at 
the hsien (county) level, or, if necessary, by public health organs at the 
provincial level. 

Plans for the high level medical training of members of minority na- 
tionalities shall be drawn up by the Ministry of Public Health of the 
Central Government; responsibility for training intermediate and basic 
level public health personnel devolves upon local public health organs 
in the minority nationality areas. 

Public health organs at the provincial and muncipal level and above 
shall establish advanced training courses for Chinese herb doctors so as 
to enable them to acquire basic, scientific knowledge of medicine; the 
curricula of such advanced training courses shall be jointly formulated 
by the Ministry of Public Health and the Ministry of Education of the 
Central Government. 

29. Decision of the Ministry of Public Health regarding the strength- 
ening and development of the basic-level public health organizations, 
approved and promulgated April 4, 1951 (1.2: 494-495). 

In pre-Communist China medical and public health facilities were 
concentrated in the large cities, leaving the populace of the rural areas 
and the industrial and mining areas with little or no access to medical 
treatment in case of illness and with little or no knowledge about how 
to preserve their health. In order to remedy this situation, this decision 
of the Ministry of Public Health calls for the systematic strengthening 
of existing public health organs at the hsien level and the creation, first 
in the southwest, the northwest, and other minority nationality areas, 
of organs in areas not having them. The larger industrial and mining 
areas were to be provided with a full complement of medical and 
public health personnel, who were to be responsible for the prevention 
and treatment of occupational diseases, the inspection of safety equip- 
ment, the dissemination of public health propaganda, the gathering of 
pertinent statistics, etc. Mobile plague prevention teams were to be sent 
to areas where there were minority nationality groups engaging primar- 
ily in animal husbandry. 

In order to strengthen and develop basic level public health organs, 
the Central Government, the government organs of the Greater Admin- 
istrative Areas, and the Ministries of Public Health and Education 
were to systematically train medical cadres, with a special emphasis on 
the training of medics and maternity nurses. Before such personnel can 
be trained, "surplus" public health personnel should be encouraged to 
go to the rural areas; unemployed medical personnel must be given 
further training for the same purpose. 



LAWS ON PUBLIC HEALTH 129 

30. Decision of the Ministry of Public Health on the adjustment of 
public-private relationships in medical and public health enterprises, 
approved and promulgated April 4, 1951 (1.2: 496-497). 

With the promulgation of this document, the PRC took significant 
steps toward the socialization of medical work on the mainland. It 
provides that, in accordance with actual needs and concrete conditions, 
the public health administrative organs shall see to it that there is a 
reasonable division of labor between the various types of public and 
private medical and public health facilities. Any medical facility in 
which there is a measure of private participation, if assigned such a 
task, must provide free services in connection with plague prevention, 
health preservation, and war movements. Medical organs jointly oper- 
ated by private individuals must be given proper guidance and assist- 
ance by local public health administrative organs; those engaging in 
private practice must be urged to organize joint public-private hospi- 
tals and clinics to supplement existing public medical organs. Privately 
operated medical facilities were to be given assistance by the public 
health administrative organs; if, however, it was found that such organs 
were not in a position to continue operation and they "voluntarily" re- 
quested assistance, they could either be reorganized as public-private 
jointly-operated medical organs or taken over by the government. 

An extended section of the document is devoted to a definition of the 
future relationship between publicly and privately operated pharma- 
ceutical factories and suppliers, the emphasis being on their carrying 
out a reasonable division of labor on the basis of a unified production 
plan. 

31. Decision of the Ministry of Public Health regarding unity and 
mutual-assistance study in the medical profession, approved and pro- 
mulgated April 4, 1951 (1.2: 498-499). 

This decision indicates that there were in China at the time less than 
20,000 doctors trained in Western medicine, while there were hundreds 
of thousands of traditional Chinese herb doctors. In order to derive the 
greatest benefit from this vast pool of medical manpower, the Ministry 
of Public Health. here dictates several actions which are to be taken to 
the end of increasing the scientific knowledge and sophistication of the 
traditional Chinese doctors. At the same time Western style doctors are 
mildly berated for their aloofness from the masses and enjoined, 
along with their traditional colleagues, to increase their political 
awareness and professional knowledge. One way in which the Western 
style doctor could express greater political awareness is clearly indi- 
cated: he can devote time after working hours to the teaching of scien- 
tific medicine to traditional Chinese doctors. In addition to such more 
or less informal scientific instruction, formal classes and study programs 



130 MEDICINE AND PUBLIC HEALTH 

are to be organized by various medical schools and groups for the fur- 
ther training of experienced herb doctors. The Ministry of Public 
Health is to set up organs to gather information about and then to 
carry out systematic research of the therapeutic possibilities of tradi- 
tional Chinese medicines and methods of treatment. Those herb doc- 
tors who have undergone advanced, scientifically oriented training are 
to be used as much as possible by the public health organs in both 
treatment and preventive work. Basic courses of scientific medicine are 
to be introduced into the curricula of herb medicine schools. 

32. Provisional regulations governing physicians, approved April 18, 
1951; promulgated May 1, 1951 (1.2: 500-503). 

The regulations define the requisite qualifications, the responsibil- 
ities, and the obligations of physicians, including alien physicians, prac- 
ticing Western-style medicine in the PRC. 

The first of eight categories of persons who may be issued the license 
essential to practice includes those who are graduates of publicly oper- 
ated medical schools either in China or abroad or who are graduates of 
a privately operated medical school with a course of study of four or 
more years. It is noteworthy, however, that these regulations provide 
that, from the time of their promulgation, those who graduate from a 
public or a private medical school, before being eligible for a license, 
must first serve for one or two years in a public or private medical facil- 
ity as assigned by the Central Government. The other seven categories 
of persons eligible for a license include those who have passed various 
types of medical examinations and those who have had varying degrees 
of successful experience in the actual practice of medicine. Four catego- 
ries of persons are eligible for a temporary physician's license; four cate- 
gories describe persons with somewhat less training and less practical 
experience than are required for a full physician's license. A list of char- 
acteristics which bar a person from eligibility for a license is given. 

Mentioned first as an obligation of the physician is obedience to the 
orders of the Central People's Government to participate in the war de- 
fending the country. Doctors further are required to observe the laws 
and regulations of the Central People's Government pertinent to medi- 
cal practice, to follow the procedures laid down by the public health 
organs, to involve themselves actively with the health of the people, to 
accept the guidance of the public health organs of the local people's 
government, and to assist in promoting health preservation work. More 
specific requirements are such matters as the taking of appropriate steps 
in case of detection or suspicion of infectious disease, delaying accept- 
ing payment for their services in the case of an emergency or a natural 
disaster, never refusing to give treatment without proper reason, never 
writing a prescription in such a way that it can only be filled by one 



LAWS ON PUBLIC HEALTH 131 

collaborating pharmacist, reporting all medical evidence of crime, and 
never inducing abortion unless the diagnosis shows that the pregnant 
woman's life is in danger. 

A graded series of punishments is prescribed for negligence, ranging 
from warning to criminal prosecution in the serious cases. 

33. Provisional regulations governing doctors of traditional Chinese 
medicine, approved April 18, 1951; promulgated May 1, 1951 (1.2: 
504-507). 

These regulations define the requisite qualifications, responsibilities, 
and obligations of doctors of traditional Chinese medicine. 

Six categories of persons eligible for licensing are set forth in Chap- 
ter 2, along with four categories of persons eligible to receive a tempo- 
rary license. Four conditions are described which bar a person from re- 
ceiving a license. 

The responsibilities and obligations of the Chinese traditional physi- 
cian described in Chapter 3 are almost identical to those set forth in 
the Provisional Regulations Governing Physicians, the major excep- 
tions being the requirement that a Chinese traditional doctor cannot 
prescribe a chemically compounded medicine or give an injection un- 
less he has had scientific training in medical treatment and that under 
no condition is he to prescribe or induce abortion. 

Chapter 4, dealing with punishments and awards, is identical to that 
in the counterpart regulations for Western style physicians. 

34. Directive of the Government Administration Council regarding 
the provision of medical treatment and disease prevention at public ex- 
pense for state employees at all levels of the people's governments, polit- 
ical parties, organizations, and their subordinate business units, June 
27, 1952 (1.3: 209-210). 

Under the provisions of the Labour Insurance Regulations of the 
People's Republic of China, first promulgated on February 26, 1951, the 
right to free medical treatment under certain conditions had been ex- 
tended to workers in certain types of industrial, mining, transport, com- 
munication, and construction enterprises. The above named directive 
basically provides for the progressive extension of this right to free 
medical services to all personnel in government agencies, democratic 
parties, people's organizations, and their departments through the coun- 
try. It stipulates that in accordance with available medical and surgical 
facilities, various localities may work out plans to provide outpatient 
and hospitalization services gradually. A timetable of target dates for 
the initial extension of these services is provided. In places where there 
are no suitable facilities available, money to cover medical expenses is 
to be indirectly issued to the sick as a provisional measure. 



132 MEDICINE AND PUBLIC HEALTH 

35. Decision of the Government Administration Council on strength- 
ening the public health personnel in national defense construction, 
passed July 13, 1951; promulgated July 18, 1951 (1.2: 508-509). 

Passed during the Korean war, this decision sets forth a policy of en- 
couraging public and private medical personnel to participate in public 
health work in the armed forces, and at the same time cautions that 
health preservation work among the masses must also be given due 
weight. It offers the incentive of increased salary, possible awards, and 
the opportunity for further study to those medical personnel who "vol- 
untarily" participate in public health work in the armed forces. Pri- 
vately practicing medical personnel are to be convinced and encouraged 
to devote part or all of their time to work in the public health organs 
so that these organs will not remain unstaffed after the exodus of public 
health workers to the armed forces. Those private practitioners who do 
not opt for working in the armed forces nor in the public health organs 
are to be "assisted" by the public health administrative organs of vari- 
ous places to participate in or to organize joint public-private medical 
organs. In the case of recent graduates of medical schools, priority is to 
be given in work assignments to defense construction work. 

36. Measures governing the organization of the Industrial Hygiene 
Commission, approved December 28, 1954 (II. 1: 513-514). 

These measures provide for the creation of an Industrial Hygiene 
Commission, the purpose of which is to be the strengthening of public 
health work in industry, the strengthening of unified guidance of such 
work, and the improvement of coordination between public health 
units in various industries. 

37. Notification by the Ministry of Public Health on strengthening 
the operations and organs involved in drug administration in various 
provinces and municipalities, March 27, 1956 (II. 3: 563-564). 

This notification aims at the tightening of control of the quality, sale, 
and distribution of all pharmaceuticals, including traditional Chinese 
herbal medicines, and pharmaceutical equipment. In addition, it calls 
for scientific research into the therapeutic properties of herbal medi- 
cines, and the study and testing of new pharmaceutical manufactur- 
ing equipment. 

38. Joint directive of the Ministry of Urban Construction and the 
Ministry of Public Health concerning supervisory work on public 
health facilities in urban planning and construction, August 16, 1956 
(II.4: 471-472). 

Probably the best example of the advanced thinking of the Commu- 
nist Chinese on ecological matters, this joint directive calls for close co- 
operation between urban construction units and public health units in 
the planning of the future development of the national economy and 



LAWS ON PUBLIC HEALTH 133 

the construction and reconstruction of cities with due regard to eco- 
nomic, public health, and aesthetic factors so as to create conditions in 
which the people can enjoy a more satisfying and healthful life. Many 
points warranting special consideration are enumerated, among them 
the establishment of "buffer zones" between industrial and residential 
areas; the planting of greenery; the location of graveyards and facilities 
for the disposal of human waste and garbage; and the protection of 
open air sources of drinking water. 

39. Directive of the Ministry of Public Health on the improvement 
of nursing work, April 3, 1957 (II.5: 335-340). 

This 1957 directive touches upon the proper utilization of available 
nursing personnel and the improvement of the basic education, ad- 
vanced training, working conditions and welfare of nurses. 

40. Directive of the Ministry of Public Health on improving the 
zoned medical service program, May 13, 1957 (II. 5: 351-357). 

With a view toward effecting better cooperation among existing med- 
ical facilities, this directive avows the intention of dividing the nation 
into various zones in which medical treatment and prevention networks 
will be established. This policy is to be carried out experimentally in 
Peking, Tientsin, and Shanghai, and then extended to large and med- 
ium-sized cities. 

41. Directive of the Ministry of Public Health on strengthening the 
leadership in basic-level public health organizations, August 7, 1957 
(II.6: 540-546). 

The term "basic-level public health organizations" encompasses joint 
clinics and health protection stations established in such locations as 
villages, towns, city blocks, enterprises, government agencies, schools, 
and agricultural cooperatives. This directive calls for the strengthening 
of the administration of these organizations, the correct understanding 
of government policy by personnel affiliated with them, the improve- 
ment of the skill of these personnel, the enhancement of efficiency, etc. 

42. Notification by the State Council approving and transmitting the 
measures of the Ministry of Public Health for directing industrial hy- 
giene work through a division of labor, August 13, 1957 (II. 6: 
546-550). 

This notification delineates in broad terms the respective jurisdic- 
tions in public health work of public health units associated with fac- 
tories and mines and the administration of these factories and mines. 

43. Directive of the Ministry of Public Health on the implementa- 
tion of the measures for directing industrial hygiene work through a 
division of labor, November 1, 1957 (II. 6: 550-554). 



134 MEDICINE AND PUBLIC HEALTH 

This supplementary directive describes in more concrete and detailed 
terms the division of labor between public health units associated with 
factories and mines and the administration of these enterprises. 

44. Directive of the Ministry of Public Health regarding the 
strengthening of public health facilities in mountainous regions, Feb- 
ruary 4, 1958(11.7: 450-453). 

Long neglected in the public health programs of previous govern- 
ments, the people living in remote, mountainous regions of China 
should be singled out for special attention in the planning and fund- 
ing of health preservation and treatment services. 

45. Notification by the Ministry of Public Health and the Ministry 
of Finance to the effect that the entire wages of hospital workers are to 
be paid from the state budget, February 5, 1960 (11.11: 207-208). 

This notification announces the government's intention to increase 
its subsidies to hospitals so that from 1960 the salary of hospital workers 
shall be paid entirely from the state budget. 

III. Chinese Medicinal Materials 

46. Several provisions of the Ministry of Public Health per- 
taining to the question of leadership and management of the free 
market for Chinese medicinal materials, issued July 26, 1957 (II. 6: 
529-530) . 

These provisions chiefly dictate that the purchase as a commodity of 
38 kinds of Chinese medicinal materials will be restricted to the Medic- 
inal Materials Corporation or cooperatives especially assigned with the 
task of their requisition-purchase; that the supply-demand factor must 
be taken into consideration in setting their price; and that purchasing 
should be carried out in accordance with an overall plan. 

47. Several provisions of the Ministry of Public Health regarding the 
business operation and control of Chinese medicinal materials, issued 
August 17, 1957 (II.6: 531-540). 

These provisions indicate that up to the end of 1956 there were some 
2,000 organs under the Medicinal Materials Corporation, employing 
some 41,900 persons. The organization of this loosely-knit group of or- 
gans should be tightened. Production of medicinal materials shoidd be 
properly planned, and the sources of supply improved through such 
steps as lending money to growers and systematically collecting medici- 
nal materials growing in the wild. The quality of the medicines made 
from these materials should be closely controlled, and distribution of 
the product should be carried out according to a scale of priorities 
based upon need. This document also includes a list of the functions 
and responsibilities of the Medicinal Materials Corporation of China. 



LAWS ON PUBLIC HEALTH 135 

48. Notification by the State Council to the effect that, at the time 
the wild-grown plant materials are fully utilized, attention must be 
paid to the supply of Chinese medicinal materials, July 11, 1958 (II. 8: 
264-266). 

In order to conserve the limited supply of Chinese medicinal mate- 
rials for their most efficient use, priority should be given to therapeutic 
uses in the case of medicinal materials which also have dietary and in- 
dustrial uses. At the same time, plans should be drawn up to increase 
the production of certain of these materials. 

49. Directive of the State Council on the question of developing the 
production of Chinese medicinal materials, October 31, 1958 (II. 8: 
282-286). 

This directive indicates that, although there has in general been an 
increase since 1949 in the production of Chinese medicinal materials, 
in the case of some of these materials there presently exists a shortage 
due to vast quantities having been used in treatment of certain diseases 
and also to their cultivation having been neglected when attention was 
focused upon the cultivation of foodstuffs. The supply of these mate- 
rials must be increased and can be increased by such steps as eradicat- 
ing the superstitious belief that they can be cultivated only in certain 
areas and systematically cultivating some materials which previously 
have been grown only in the wild. In making plans to increase produc- 
tion, proper attention must be given to quality control and efficient 
purchase and distribution. 

50. Notification by the State Council transmitting and approving the 
report of the Ministry of Public Health on the question of Chinese me- 
dicinal materials, March 7, 1959 (II.9: 277-278). 

This notification reports that the State Council has approved the re- 
quest of the Ministry of Public Health that around J MP 30,000,000 be 
allocated for the advance purchase of Chinese medicinal materials in 
an effort to assist growers in increasing production of these materials. 

5. Notification by the Ministry of Public Health on seizing the op- 
portunity of vigorously promoting the work of producing and purchas- 
ing Chinese medicinal materials during the autumn and winter sea- 
sons, August 21, 1959 (11.10: 405-408). 

The systems of growing, gathering, and purchasing Chinese medici- 
nal materials, an estimated 80% of which are grown in the wild, should 
be improved as this notification stipulates, recommending such concrete 
steps as adequately compensating agricultural workers who gather the 
wild materials, having the purchasing done by public health personnel 
with a knowledge of pharmacology, and encouraging producers to pro- 
vide the best possible conditions for growth. The government, it is indi- 



136 MEDICINE AND PUBLIC HEALTH 

cated, is trying to regulate the dosage of medicines compounded from 
these medicinal materials in an effort to conserve the supply and also is 
attempting to eliminate the attitude that one should take certain medi- 
cines whether one really needs them or not. 

52. Directive of the Ministry of Public Health regarding the all-out 
seizure of the opportunity of carrying out the planting of spring medic- 
inal materials, as well as the promotion of collecting wild-grown medic- 
inal materials, March 9, 1960 (11.11: 209-212). 

This directive proclaims the necessity of launching a spring cam- 
paign to carry out the planting of cultivated medicinal materials and 
the gathering of wild-grown ones which reach the proper stage of ma- 
turity in the spring. Training classes and short-term schools should be 
set up to train the people in the proper scientific techniques of cultiva- 
tion of Chinese medicinal materials. The target is the planting of 
6,000,000 hectares of medicinal materials. 

53. Notification by the Ministry of Public Health on the question of 
a general survey of sources of wild-grown medicinal materials, March 
11, 1960 (11.11: 212-215). 

This notification makes public a plan to carry out in three years 
(1960-1962) a systematic survey of the sources of wild-grown medicinal 
materials under the leadership of the Party and with enlistment of the 
masses. While the plan estimates that there are more than 2,800 kinds 
of wild-grown animal and plant medicinal materials, only about 1,000 
varieties were being handled at the time by the organs dealing with me- 
dicinal materials. An enumeration of units and groups to participate in 
this survey gives evidence of its importance to the regime, as does the 
description of the approach to be taken in conducting the survey. 

IV. Miscellaneous 

54. Rules for dissecting corpses, approved April 28, 1957, is- 
sued July 15, 1957 (II.6: 525-529). 

These rules describe the procedures to be followed in the dissection 
of corpses for teaching purposes in medical schools and for determina- 
tion of the cause of death for legal and non-legal purposes. 

V. Conclusions 

The absence, after Volume 11, of legislation on public 
health in the second statutory collection is so conspicuous that it de- 
mands some explanation. The point to be stressed in this explanation 
is that the failure to include further legislation on public health does 
not in itself necessarily point to a downgrading of the importance of 



LAWS ON PUBLIC HEALTH 137 

public health by the Communist Chinese authorities or need it imply 
that there were no further notable developments in public health after 
1960. The first, obvious observation is that not every legal document 
issued in the PRC was selected for inclusion in the statutory collections. 
But the failure to include legislation on public health in Volumes 12 
and 13 also must be viewed against the background of the decrease in 
the overall size of these two volumes in comparison to previous volumes 
of the second series. No volume of Volumes 1 through 10 numbers less 
than 300 pages, even though nine of these ten volumes cover only six- 
month periods; and one has a total of 887 pages. Volume 11, however, 
has only 230 pages! Volume 12 has only 148 pages; and Volume 13, 
which covers a twelve-month rather than a six-month period, has only 
280 pages. This decrease in the size of the volumes of the second 
statutory compilation is one reflection of the fact that, after having 
reached its heyday in the mid-1950's, formally enacted and published 
law in general played an increasingly minor role in the People's Re- 
public of China even before the onset of the Cultural Revolution. 
Public health hence was not the only area in which the amount of 
formal legislation declined. Third, as we have indicated previously, not 
subscribing to the notion of the rule of law, the Peking regime has at 
no point felt it essential that every action proceed from a previously 
enacted statutory base. Examination of the development of public 
health in the PRC, especially in the period after 1960, necessitates 
one's looking at various types of available sources other than the pub- 
licly promulgated legal ones. Doubtless the most valuable sources of a 
legal or quasi-legal nature are not available. From what one finds in an 
examination of actual practice, one perhaps can infer that certain di- 
rectives not accessible to us have been issued to those administering 
the public health system. This body of unpublished instructions to 
state and party cadres having the character of law always exists in the 
PRC: its importance and perhaps its volume waxes and wanes with 
the fluctuations in the amount of formally promulgated legal docu- 
ments. 

It appears to us that, in comparison with that on other topics, legisla- 
tion on public health in the PRC is rather complete, given the nature 
of Communist Chinese legal documents. In writing its laws, the Peking 
government does not aim at full, technical statements devoid of loop- 
holes, but at a statement of policy vague enough to permit flexibility in 
implementation, simple enough to be readily understood by the average 
citizen, and inspiring enough to constitute effective propaganda. We 
feel that the examination above of 54 legal documents has yielded a 
rather complete statement of the basic policies which have prevailed in 
the area of public health in the PRC since 1949. The emphases have 



138 MEDICINE AND PUBLIC HEALTH 

changed somewhat over the years, particularly since the thought of Mao 
Tse-tung became the sun illuminating every aspect of life in Commu- 
nist China, but at least the roots of every basic policy in public health 
can be found in even the earliest legal documents considered here. 

The very consistency in public health policy in the PRC may have 
served to diminish the volume of law on this topic, for Communist 
Chinese laws often are issued in response to changes in policy. Public 
health likely has been an area relatively free of controversy on the 
mainland. The question rarely has been what policy to pursue; it in- 
stead has been from the beginning how to make adequate resources, 
both human and financial, available for the implementation of pre- 
viously decided policy. Communist Chinese ideology dictates that pol- 
icy in public health be oriented toward the masses, and the Peking 
government pays much more than lip-service to its ideology. The orienta- 
tion stemming from the ideology is doubly determined by the need to 
have the people in robust health so as to be able to withstand the physi- 
cal demands made upon them in the interests of the nationalistic policy 
of rapid development of the agricultural and industrial economy. Com- 
munist Chinese policy in public health work has flown readily from the 
basic orientation toward the masses; there has been little need for volu- 
minous legislation to chart vacillations in policy and approach. 

Another feature of the above description of public health legisla- 
tion in the PRC which merits further comment is the proportionately 
great number of documents, especially in the latter years surveyed, de- 
voted exclusively to Chinese medicinal materials and the frequent men- 
tion in other documents of traditional Chinese herb doctors. From the 
beginning, expediency dictated that the regime utilize fully both those 
trained in traditional Chinese medicine and the pharmacopoeia asso- 
ciated with their practice. The regime's public health policy and pro- 
grams were ambitious ones, but their success was crucial to even more 
ambitious economic policies and programs. Further, if one succeeds in 
bettering the health of the masses, one has a tangible achievement 
which one can put on display as evidence of one's genuine concern for 
the people's lot and thus perhaps win support in other policy areas 
where success comes more slowly, with greater exertion, and with less 
personally felt benefits. The Communist Chinese leaders initially may 
have had greater faith in Western-style medicine than in their "home- 
grown" variety, but doctors trained in Western medicine were pitifully 
few, and Western pharmaceuticals not only limited and expensive, but 
also unfamiliar and hence a cause of fear to many of the superstitious 
Chinese. Traditional Chinese doctors and medicinal materials likely 
were brought into public health work to the extent that they were at 
least in part because of a begrudging attitude that some knowledge and 



LAWS ON PUBLIC HEALTH 139 

some therapeutic effectiveness were better than none. The early laws 
make it evident that the regime was concerned that the traditional doc- 
tors get further and more scientific training and that the therapeutic 
properties of traditional medicinal materials be scientifically ascer- 
tained. Though expediency was long operative in the regime's stance 
toward traditional Chinese medicines and medical practitioners, and 
though the need for their use perhaps increased with the worsening of 
Sino-Soviet relations and China's progressive self reliance, a motivation 
other than expediency becomes more and more evident in the later doc- 
uments surveyed here. Traditional Chinese doctors and medicines be- 
came a source of genuine pride to the leadership. One cannot doubt 
that those in charge were convinced of the effectiveness of the tradi- 
tional remedies and proud of that effectiveness, if one considers the 
sizeable expenditure of human and financial resources which implemen- 
tation of the legal documents on Chinese medicinal materials would re- 
quire. The very fact that so many documents on traditional Chinese 
medicines were included in the second statutory compilation is a good 
indicator of the import which the regime attaches to them. 

Study of legal documents on public health in the PRC has a value 
exending beyond the knowledge one thereby acquires about a specific 
topic. All areas of policy in the PRC are so intimately entwined, that 
knowledge of one area carries over into one's understanding of other 
areas. The basic orientation, the approach, the spirit, and some of the 
techniques one finds in legislation on public health are readily discern- 
ible in, for example, labor legislation and legislation on the family. 
The author hopes that this study of public health legislation of the 
PRC encourages specialists in public health and other aspects of the 
contemporary Communist Chinese scene to make use of the available 
legal sources. 



140 MEDICINE AND PUBLIC HEALTH 

REFERENCES 

1. Chung yang cheng fa kan pu hsiieh hsiao kuo chia fa chiao yen shih (Office of 
Teaching and Research on State Law of the Central Political -Legal Cadre 
School), compiler, Chung hua jen min kung ho kuo hsien fa hsoeh hsi ts' an 
k'ao tzu liao (Reference Materials for the Study of the Constitution of the Peo- 
ple's Republic of China). Vol. I. Peking: Fa Hi ch'u pan she (Legal Press). 1957, 
p. 93. 

2. Ibid., p. 99. 

3. Ibid., p. 102. 

4. Fundamental Legal Documents of Communist China, edited by Albert P. 
Blaustein, South Hackensack, New Jersey: Fred B. Rothman &: Co., 1962, p. 51. 

5. Ibid., p. 30. 

6. The following system of citation is used in this article: The initial upper case 
roman numeral, either "I" or "II", refers to the first or the second series of 
volumes making up the two statutory compilations; in other words, the roman 
numeral "I" refers to Chung yang jen min cheng fu fa ling hui pien (Collection 
of Laws and Decrees of the Central People's Government) , and the roman 
numeral "II" refers to Chung-hua jen kung ho kuo fa kuei hui pien (Collection 
of Laws and Regulations of the People's Republic of China.) The arabic numeral 
following the roman numeral refers to the volume of the series in Avhich the 
Chinese text of the document appears. The arabic numerals following the colon 
refer to the page number on which the Chinese text of the document appears. 
(LI: 631-633) then means that the Chinese text of the document appears on 
pages 631 to 633 of Volume 1 of the first compilation, Chung yang jen min 
cheng fu fa ling hui pien. 

The publication schedule of the two series is as follows: 







Chung yang jen min cheng fu 


fa ling 


hui 


P 


ien 








Vol. 
1 


No. 




Coverage 
Sept. 1949-Dec. 1950 










Publ 


ication 
1952 


Date- 


2 






1951 












1953 




3 






1952 












1954 




4 






1953 












1955 




5 






Jan.-September 1954 












1955 








Chung 


hua jen min kung ho kuo fa kuei hui 


pien 








Vol. 


No. 




Coverage 










Publ 


ication 


Date 


1 






Sept. 1954-June 1955 












1956 




2 






July-Dec. 1955 












1956 




3 






Jan-June 1956 












1956 




4 






July-Dec. 1956 












1957 




5 






Jan-June 1957 












1957 




6 






July-Dec. 1957 












1958 




7 






Jan-June 1958 












1958 




8 






July-Dec. 1958 












1959 




9 






Jan-June 1959 












1959 




10 






July-Dec. 1959 












1960 




11 






Jan-June 1960 












1960 




12 






July 1960-Dec. 1961 












1962 




13 






Jan 1962-Dec. 1963 












1964 





HEALTH CARE FOR RURAL AREAS 



Susan B. Rifkin, B.A., M.I.A. 



In the face of adverse conditions of overpopulation, limita- 
tion of resources and a technological base, factors shared by the develop- 
ing nations, the People's Republic of China is attempting to devise a 
health system which de-emphasizes high Western standards of medical 
care and is geared to meet the less sophisticated needs of the local 
population. This system relies upon prevention rather than cure, upon 
the rapid expansion of health facilities and upon extensive and often 
intensive use of traditional practitioners, health teams and medical 
auxiliaries in an attempt to make possible health and medical care for 
most of China's 80 percent rural population. By focusing on these pro- 
grams, the Chinese are diverging from large investments in curative 
medicine and highly skilled manpower, which would be available only 
to wealthy urban classes. 

A major reason for China's apparently impressive expansion of rural 
health services is the effort of the leadership to coordinate health pro- 
grams with economic plans. The Chinese Communists early recognized 
the need to protect China's largest resource, its manpower. Health prob- 
lems became not only the concern of medical professionals, but also of 
the economic and political strategists. For this reason, health policies 
are an integral part of, rather than excluded from, overall development 
planning. 

The development of health services in China has followed the vari- 
ous stages of economic development. Based on the principle that "to de- 
fend the life and health of the people by wiping out diseases means to 
protect the most important and the most important productive force in 
the world," J health policies have been formulated within the broad 
guidelines promulgated by the Chairman of the People's Republic of 
China, Mao Tse-tung. His four standards demand that medical care 

141 



142 MEDICINE AND PUBLIC HEALTH 

must 1) serve the workers, peasants and soldiers, 2) put prevention 
first, 3) unite Western and traditional medicine, and 4) co-ordinate 
medical campaigns with mass movements. 2 

The period from 1950-1952 was one of economic rehabilitation re- 
flected in the health sphere by the concern of the leadership in provid- 
ing the basic organization for health and medical care and in eradicat- 
ing as quickly as possible epidemic diseases. In the first instance, the 
government not only established the Ministry of Public Health in 1949 
and re-structured the already existing hospitals and research centers but 
also took measures to mobilize the trained medical personnel. Private 
practice was strongly discouraged and Western doctors were urged to 
join practitioners of traditional medicine in organizing United Clinics 
to make their services available to the state. Medical schools expanded 
in order to train more needed personnel for public service. 

To provide care for China's predominately rural population and to 
disperse medical talent from its heavily concentrated urban base, other 
measures were taken. Upon the remnants of an incipient rural health 
structure created during the Republican period (1911-1949), the 
Chinese began to extend the health network. To carry out the dictum 
of the First National Health Congress (1950) that health work should 
serve the masses, 3 four basic health units were reconstituted: 1) The 
Epidemic Prevention Stations had responsibility for the reporting of, 
and inoculations against, all communicable diseases. Under the con- 
trol of local authorities, they carried out public health work and dealt 
with sanitation problems in their region. They provided the basis of 
the early rural health structure; 2) Affiiliated Clinics were established 
in areas where there were on other health units to administer medical 
care to and carry out health programs for local people; 3) The Red 
Cross and Red Crescent Societies, which had been present in China 
since 1904, now had responsibility for sanitation work through the use 
of environmental inspection teams and for health education programs. 
They also carried out their traditional duties of rendering first aid in 
times of disaster; 4) Spare Time Clinics were established in factories, 
mines, etc.,— their business hours so arranged to meet the off duty hours 
of the workers. Duties included rendering first aid to workers in case of 
emergency, conducting routine health examinations, giving inocula- 
tions against infectious diseases and checking absenteeism due to ill- 
ness. All four units were responsible for health education. 

Health teams led by members of the core of 18,000-20,000 Western 
trained doctors present in China in the early 1950's 4 staffed these units. 
The viability of their work depended on the auxiliary worker who 
could carry out a number of health and medical measures and release 
the precious time and skills of the professional physician. Auxiliary 



HEALTH CARE FOR RURAL AREAS 143 

workers were divided into four groups: 1) the specialist, educated for 
two years in one field of medical care; 2) the paramedical professional, 
such as nurses and lab technicians who studied two/three years to per- 
fect their skills; 3) the hygiene workers whose three/six months train- 
ing focused on environmental problems and disease control; and, 4) the 
part-time worker who in a one/three month training period learned to 
give vaccinations and to recognize and report endemic diseases. 

Auxiliaries learned both curative and preventive techniques 5 and by 
participating in both types of activities made possible the maximiza- 
tion of their much demanded skills denied by the separation of prophy- 
laxis and curative work characterized in Western medical training. 
Such flexibility attempted to encourage medical people to make use of 
indigenous resources and talents and to develop treatment and skills 
most appropriate for local conditions. 

Early achievements of the health teams included reported successes in 
the anti-syphilis campaigns, and the rapid creation of health services for 
the minority peoples of China to prevent the threatened extinction of 
some of these tribes. The teams became extremely important as a means 
by which to get health care and education to remote areas virtually ne- 
glected by government health services up until this time. Their contin- 
ued use brought new standards of medical and health protection 
to the Chinese people. 

Using growing medical organization and the health teams, the 
leadership turned its attention to methods of disease eradication. In 
order to implement preventive measures such as vaccinations and to im- 
pose conditions of sanitation for the control and abolition of conta- 
gious diseases, the government established mass campaigns for the mo- 
bilization of the entire population. Mass campaigns for health purposes 
were called "Patriotic Health Campaigns" and were first initiated in 
1952 to urge the people to improve village water sanitation and to erad- 
icate the four pests (rats, flies, mosquitoes and bedbugs) which were 
the carriers of certain infections whose widespread presence was al- 
legedly due to the use of germ warfare by the Americans in the Korean 
War. 6 Poorly organized, these initial campaigns were soon restructured 
as "Shock Attack" movements providing techniques for instant partici- 
pation of the people whenever the authorities felt a health campaign 
necessary. "Shock Attacks" which proved effective for an intensive effort 
for a short period of time, reached their zenith in the Great Leap pe- 
riod of 1957-58 at a time when agriculture became increasingly impor- 
tant in the economic development of China. Thereafter, campaigns be- 
came institutionalized as seasonal affairs aimed at the eradication of all 
communicable disease as well as the four pests. They also had intrinsic 



144 MEDICINE AND PUBLIC HEALTH 

value as a vehicle for health education and as machinery for the dissem- 
ination of health propaganda in both urban and rural areas. 

The period of the First Five Year Plan, 1953-57, emphasized the de- 
velopment of heavy industry rather than agriculture and accordingly, 
health policies focused on programs to benefit urban, industrial 
workers. 7 The mass campaigns continued to hold an important place in 
health plans as did the training of new personnel but little concern fo- 
cused on rural health organizations. Then by 1956, economic planners 
realized the importance of agriculture as a means of capital formation 
and began to reformulate their development strategies. 

With the promulgation of the Twelve Year Plan for Agricultural De- 
velopment in 1956, the Chinese chose to stress agriculture as the basis 
of its economic growth and to link health explicitly with agricultural 
production. "Our aim is to fully utilize this favorable condition— large 
population and abundant manpower— in China in order to accelerate 
the development speed of production to the highest degree". 8 The 
Chinese formed agrarian co-operatives and focused health activities in 
the countryside where the large population density provided the neces- 
sary manpower to implement the economic goals. To ensure that all 
people had access to some type of medical care, attention centered on 
the expansion of medical facilities and manpower. The policies formu- 
lated at this period to achieve these goals have remained, with some 
modification, the basis for the development of health services in China. 

The cornerstone for the development of rural health programs was a 
revived system of state-supported hsien (county) hospitals and health 
centers which had been established in China in the 1930's. County hos- 
pitals were generally divided into the following departments: internal 
medicine, surgery, obstetrics, pediatrics, traditional Chinese medicine, 
radiology, laboratory and other specific departments, and a dispensary. 
In addition to providing medical care, these units organized patriotic 
health campaigns, aided smaller health units, sent health teams to re- 
mote areas and trained medical personnel. By 1957 most of China's 
2000 counties had at least one hospital. 9 

In addition to those established in the counties, hospitals were set up 
in market towns, in more remote mountain areas and among the mi- 
nority tribes. Such distribution allowed better health and medical serv- 
ices in the countryside and better suited the dispersion of the rural 
population. In areas where no hospital was constructed, clinics, sub- 
clinics, health stations and mobile hospital units were established as 
local health centers. By 1957 the number of group practice clinics and 
sub-district health clinics were in excess of 50,000. Health stations es- 
tablished in the agricultural producers' co-operatives exceeded 10,000. 10 

In 1958, with the formation of the communes, the rural health net- 



HEALTH CARE FOR RURAL AREAS 145 

work was further modified. 11 A major feature of this period was the de- 
centralization of responsibility from the state to the local level. Al- 
though the state continued to operate the county hospitals, the com- 
munes ran their own basic medical units. At this time, the rural health 
center or institute became the responsible organ for all local health ac- 
tivities. 

The health center, organized around the health centers of the former 
agricultural co-operatives, was under the direction of the commune's 
Management Committee's Department of Culture, Education and 
Health but was professionally guided by the hsien hospital or health 
center (in the Chinese documents these two terms are used interchange- 
ably). It had responsibility for the health and medical work of the 
smaller units— the production brigades and their subsidiary compo- 
nents, the production team. A typical organizational pattern for com- 
mune health work is found in Yanglo commune in Chung-yang hsien in 
Shensi province, (see Fig. 1). Duties of the health center included: 
care for out-patient and regional health work; direction of mass cam- 
paigns; the investigation and control of contagious diseases; the inspec- 
tion of public mess halls, nurseries, kindergartens and maternity hospi- 
tals; the delivery of medical care; the training of medical people and 
planning and implementation of all preventive programs. 

In order to staff these expanded facilities, the Chinese made several 
important decisions. As a first measure, steps were taken to pay more 
than lip service to the 500,000 practitioners of traditional medicine. 15 
As early as 1954, the Chinese Academy of Traditional Medicine was es- 
tablished and in the 1956-58 period, a concentrated effort was begun to 
introduce both traditional doctors and medical theory into the univer- 
sity classroom. A search for the synthesis of the two systems became a 
goal and strongly encouraged students to study both systems (this call 
to study both types of medicine has become increasingly imperative in 
the period which has followed the Cultural Revolution) . In addition, 
Western trained doctors were urged to study Chinese medicine in spe- 
cial courses devised for this purpose. By 1958, there were reportedly 
over 13 colleges and several hundred secondary schools of traditional 
medicine established which were training 70,000 apprentices. 14 

Under this new official attitude, traditional doctors in increasing 
numbers joined the national and municipal public health services. 
They were assigned to hospital and clinics of various types and were 
integrated into the existing organizational system. In the rural areas, 
their increased presence provided an alternative type of treatment to 
Western medicine because here, as the Chinese indicate, "the tradi- 
tional methods of treatment are preferred because they are simple and 
effective and appropriate to the constitution and habits of the Chinese 



146 



MEDICINE AND PUBLIC HEALTH 



People's commune 



Central Hospital 



Central Maternity 
hospital 



Production brigade 



Branch Hospital 



£ 



Outpatient 
Department 



Production team 



Branch maternity 
hospital 



L_ 



1 



Medical 
Station 






Health Office 



Public health 
worker 



_J 



Family maternity 
hospital 



Mid wives 



Figure 1. System of Basic-level Health Organizations at the Yung-lo People's Commune. 

people". 15 The traditional doctors staffed rural health centers, trained 
auxiliaries and carried out health team work. In 1956, 30,000 tradi- 
tional practitioners had been incorporated into government public 
health organs. 16 

Another measure first taken during the Great Leap period to meet 
rural health need was the transfer of urban medical personnel to the 
countryside to lead and/or serve on health teams in rural areas. Follow- 



HEALTH CARE FOR RURAL AREAS 147 

ing the policies of decentralization of authority, encouragement of the 
development of indigenous local resources through the organization of 
the communes and uniting "theory with practice," the Chinese leader- 
ship called for highly trained medical doctors to travel the hinterland 
and to teach local people to build and support local health services. 
On a rotation system which provided for one year's leave of absence 
from their urban institutions, 17 city medical personnel rapidly ex- 
panded the ranks of rural medical services. 

Once in the countryside, the senior medical doctors were stationed in 
the rural hospital where their talents could be used to direct the organi- 
zation of new health services and the training of local staff. 18 In addi- 
tion, they not only used their medical skills to treat the peasant popula- 
tion but also applied their talents to seek solutions to common rather 
than rare disease problems. The younger medical doctors who came from 
the city, for the most part, travelled with the mobile medical teams and 
applied their medical specialty to treat and train local people in the 
communes. As staff members of health units called mobile hospitals, 
these doctors would recruit some of the county and local medical work- 
ers, travel to areas with little or no health and medical care services, 
set up a central clinic and spend 2-3 months checking all the local in- 
habitants. They would treat the cases they could and refer the rest to 
more advanced clinics. Their presence also encouraged the institute per- 
sonnel to raise their own health standards. Rural service continued to 
be strongly encouraged for newly graduated doctors. The Chinese Med- 
ical Journal reported that most of 1963's graduate doctors (25,000) were 
sent for duty in county hospitals or mining enterprises. 19 

A third step was to create a new type of auxiliary worker, the fore- 
runner of the present "barefoot doctor" who was educated in the train- 
ing centers that proliferated during the Great Leap period. Studying 
medicine on a part-time basis or in spare time schools, these workers 
were trained to carry out rudimentary treatment, and preventive and 
sanitation work. The appearance of this type of personnel enabled the 
employment of these people in health work during slack seasons and 
provided means of "on the spot" treatment. It also created a corps of 
concerned locals who had stakes in the good health of the commune. 

All these steps rapidly augmented the ranks of available manpower. 
Excluding the traditional doctors between 1957-58, demographer Leo 
Orleans claims that there was an average annual increase of 198,000 
total medical people as compared with 173,000 in the 1952-57 period. 20 

In the aftermath of the tremendous economic push of the Great Leap 
period and with the withdrawal of the Soviet technicians in 1960 the 
Chinese leadership began to consolidate its economic plans. "Self-reli- 
ance" began to emerge as a major theme for development and a search 



148 MEDICINE AND PUBLIC HEALTH 

for the most appropriate use of available material and manpower re- 
sources commenced. In recently available documents from Red Guard 
sources, this period (1960-65) has been characterized as that of domi- 
nance by the technocrats and bureaucrats and development of urban 
areas rather then the countryside. In the field of health and medical 
care, it is an era described as one in which the drive for excellence in 
medical research and training diverted scarce resources from the estab- 
lishment of health services for the masses. 21 

Although no doubt there was a drive for expanison of advanced re- 
search and of skilled manpower, it appears that in the rural areas most 
phases of economic planning were by no means ignored. The leadership 
still advanced agriculture as the basis of economic growth and contin- 
ued to take steps to protect the health of the rural agrarian manpower. 
The Chinese consistently stressed the need for preventive programs and 
for medical treatment for the peasants in order to increase agricultural 
production and the need to improve and expand health services. Facili- 
ties greatly expanded: in 1940 there were 1,775 county health centers; 22 
in 1957 there were 60,000; 23 and by 1962 the reports indicated 210,000 
health centers had been established in these rural areas. 24 

With regard to medical manpower, training of medical auxiliaries 
and diffusion of skilled medical doctors to rural areas remained policy 
goals. Medical colleges were set up in many of the provinces and stu- 
dents were taught to combine scientific research with production objec- 
tives. In addition, the Chinese Academy of Medicine (CAM) sent some 
of its top rank staff to the rural areas to assist in the control of endemic 
diseases and to do other health work. In 1964, nearly 500 men from 11 
research institutes visited over 23 provinces and 70 health centers. 25 

In the months immediately prior to the onset of the Cultural Revolu- 
tion in 1966, concern for rural health services reached a new high. In 
1965, Mao issued his famous "June 26" directive stating "In health work 
put stress on the rural areas". 26 In response to this appeal, the number 
of urban personnel travelling to the countryside rapidly increased. In 
the five months following issuance of this command, over 1,600 mobile 
medical teams comprising 29,000 urban medical professionals were 
in the rural areas. Led by such prominent figures as Dr. Huang Chai-ssu, 
President of the Chinese Academy of Medical Sciences, these teams were 
organized on a large scale to involve large numbers of health and medi- 
cal people on all levels. 27 In addition, the leadership established a Rural 
Health Institute and designated the Institute for Labour Hygiene, En- 
vironment Sanitation and Nutrition to provide support for the efforts 
of the health teams in the areas of rural disease control and health. 

The period of the Cultural Revolution and the era after has seen a 
more explicit development of the policy of "self-reliance" through the 



HEALTH CARE FOR RURAL AREAS 149 

stress on the three principles of: (1) developing both industry and agri- 
culture, (2) equalizing development of urban and rural areas, and (3) 
closing the gap between mental and manual labor. In the health field 
these policies concentrated on the expansion and diffusion in the rural 
areas of the mobile medical teams; the rapid increase of the medical 
auxiliary corps; and the widespread implementation of the cooperative 
medical system instituted within the commune. In addition, policies 
have reflected an increased concern with need for methods by which to 
institutionalize the newly expanded rural health system. 

In the post- 1965 era, nearly all urban medical personnel who are sent 
to the countryside become members of mobile medical teams. The trans- 
fer of personnel has become a permanent long range goal of the Chinese 
with efforts made to keep one third of all urban medical people in the 
rural areas at any given time. 29 The work in which they engage, in ad- 
dition to treatment and training, includes guiding local mass health 
campaigns; doing research on prevention and cure of the disease most 
common to the places they visit; and lecturing and teaching about 
health education and important medical techniques to upgrade local 
personnel. Urban teams live in the homes of the local peasants and 
learn to exist without city comforts. They also engage in manual labor 
through aiding in agricultural work and assisting in the physical build- 
ing of rural health facilities. 29 

A major task for the mobile medical teams is contribution to the ex- 
pansion of the corps of medical auxiliaries through the training of the 
"barefoot doctors." These auxiliaries, like their Great Leap predeces- 
sors, learn both Western and traditional medicine during the agricul- 
tural slack season in order to serve the community in which they live. 
Depending on a system of referral to more highly trained personnel, on 
the periodic visits from the physicians of the mobile medical teams, on 
preventive medical techniques and on high morale of and acceptance 
by the people whom they treat, these medical workers give substance to 
the latest medical policies. Their duties include treatment of minor ail- 
ments, dissemination of birth control information, and the responsibil- 
ity for the organization of health education programs, patriotic health 
campaigns and general sanitation work in their locale. The Chinese 
press states that their present number is over one million persons. 30 

The work of the "barefoot doctors" is not only supported by the tra- 
ditional medical assistants, nurses, midwives, laboratory technicians, 
and the like, but also by thousands of public health workers who learn 
to prevent and treat minor injuries and diseases, administer preventive 
shots and know how to make tourniquets, bandages and splints. They 
also know some acupuncture techniques to treat simple cases. In late 
1969, when Mao commanded a preparation against war, the press re- 



150 MEDICINE AND PUBLIC HEALTH 

ported the rapid appearance of the family health worker, a member of 
each commune household who was equipped with first aid techniques to 
treat minor problems and to aid actively sanitation work and health 
campaigns. 31 

The cooperative medical scheme first appeared in the reorganization 
plans of the Great Leap period. However, it was not until the Cultural 
Revolution and after that its broad adoption has become apparent. Ba- 
sically, the system calls for both the commune and the commune mem- 
ber to contribute a fixed amount per annum for medical care. In re- 
turn, the patient pays only a minimal amount of money for treatment 
and medicines he receives. While the exact scheme varies from com- 
mune to commune the system adapted by the Chunhsing production 
brigade, Kukong county, Kwangtung province seems to be typical. 

From 1957-1964 when the brigade was the basic accounting unit, 
medical expenses were paid by the brigade and patients paid only a reg- 
istration fee. From 1965, when the production team became the basic 
accounting unit, the scheme was restructured so that the commune, bri- 
gade and production team members each lay aside a fixed amount per 
year. In recent years, the contribution from an individual member is 
about one yuan (a yuan is equal to about $.50 according to the 1970 
rates of exchange). The production team contributes one yuan per cap- 
ita from its welfare fund and the production brigade gives 2000 yuan 
per annum. Given the size of the brigade, the total is about 8000 yuan 
per year. 32 Patients' fees are paid yearly by the brigade. The establish- 
ment of cooperative medical schemes not only has made medical serv- 
ices more accessible to local inhabitants by providing finances for im- 
mediate treatment but also has relieved the state from heavy investment 
for similar returns in local medical and health care services. 

Culmination of self-reliance in the manpower and resource mobiliza- 
tion policies can be witnessed in reports of the emergence of "red medi- 
cal villages" where all inhabitants "work for better health" by collect- 
ing herbs, making their own medicines and emphasizing prevention 
but combining it with cure. In these areas each brigade has its own 
pharmacy; each village has its own "barefoot doctor;" several families 
have joint first aid stations; and each family has its own health 
worker. 33 These villages represent the attempts of the Chinese to reduce 
the inequality between medical standards in the urban and rural areas 
and to provide medical and health care for all its 800 million people. 

While all these measures provide sensible solutions to obvious needs, 
the chaos of the Cultural Revolution made the task of establishing an 
integrated rural health infrastructure difficult. By 1968 it was apparent 
that the professional medical people could not carry out their duties as 
members of the mobile medical teams and participate in the political 



HEALTH CARE FOR RURAL AREAS 151 

activities of the period simultaneously. In order to prevent a break- 
down of the health system, the Chinese leadership turned to the one 
group that had remained relatively cohesive during this era of strug- 
gle, the People's Liberation Army. By June 1969 the PLA had sent 
more than 4,000 medical teams and 30,000 men to the countryside. 34 In 
the one year period ending July 1970 they had sent 6,000 teams with 
80,000 members for rural health work. 35 

The PLA has become the model for emulation for all medical and 
health work in the country. Medical professionals are urged to establish 
hospitals in the character of the Red Army hospital for the civil war 
period (1937-49). To meet the directives for rural health work, medi- 
cal college curricula often imitate the Red Army Health School 
founded in Juichin by Mao Tsetung in 1931. The structure stresses de- 
centralization of educational facilities by establishing university 
branches in local areas. It also focuses on practical experience as a prin- 
ciple of instruction by sending students to treat and teach throughout 
the countryside. 36 "Barefoot doctors" are called upon to copy the feats of 
the PLA medical teams. It is evident the future role of the army will be 
an important factor in Chinese rural health developments. 

Despite the problems that continue to plague the present system, the 
Chinese seem to be making inroads into their massive health problems. 
By attempting to modify the tradition of Western medical systems, 
which continue to maintain an emphasis on curative medicine adminis- 
tered by "fully qualified" doctors available by necessity of cost to the 
urban rich, the Chinese may be discovering ways of letting health care 
"serve the people." Through the use of health teams and auxiliary 
workers, through the implementation of mass campaigns, through the 
integration of Western and traditional medicine and practitioners and 
through a continuing emphasis on health work in the rural areas, the 
health system sets guide-lines for distributing medical resources in 
order that the majority of people have access to health protection and 
medical care. For this reason and for many others, the new Chinese 
medical and health care system will continue to be of interest both to 
the medical profession and national policy makers who must find solu- 
tions for the existing medical care problems among the rural peoples of 
the world. 



152 MEDICINE AND PUBLIC HEALTH 

REFERENCES 

1. New China News Agency (hereafter cited as NCNA): December 12, 1958. 

2. Chinese Medical Journal (hereafter cited as CM]) 77: 16-18 July 1958. 

3. Peoples China: 9-11, October 1, 1950. 

4. Ibid. 

5. Ibid. 

6. For the report of the international commission which investigated these charges, 
see CMJ 70: 337-651, September-December, 1952. 

7. NCNA: September 24, 1954. 

8. Jen Min Jih Pao (People's Daily): July 22, 1958. 

9. CMJ 4: 412-416, June, 1965. 

10. CMJ 75: 953-957. December, 1957. 

11. The size of a commune varies. The largest have about 50,000 people. 

12. Jen Min Pao Chien (People's Health) 1: 6 June. 1959 cited in U.S. Department 
of Commerce Joint Publications Research Service (hereafter cited as JPRS) 5484. 

13. Jen Min Shou T'se (People's Handbook). Peking: 1951, for this figure. 

14. Peking Review 43: December 23, 1958. 

15. CMJ 78: 103-105, February, 1959. 

16. Jen Min Jih Pao (People's Daily): September 12, 1957. 

17. NCNA: January 28, 1958. 

18. Ibid. 

19. CMJ, Op. Cit., June, 1965. 

20. Orleans, Leo: "Medical Education and Manpower." Comparative Education 
Review: 20-42, February, 1969. 

21. Chen, Jerome: Mao Papers: An Anthology and Bibliography. Oxford University. 
London, 1970. 

also Current Scene: May 1, 1968: June 15, 1969 and December 15, 1969. 

22. Gould, Sidney, editor: Sciences in China. Washington, D.C.: AAAS, 1960, pp. 
384-5. Chen. W. Y.: "Medicine and Public Health." 

23. NCNA: August 21, 1957. 

24. NCNA: September 21, 1962. 

25. Kuang Min Jih Pao (Enlightenment Daily): May 21, 1965. As cited in JPRS 
30758. 

26. Chen, Op. cit. p. 100. 

27. CMJ 85: 143-149, March. 1966. 

28. Ibid. 

29. Horn, J.: Aivay with all Pests. Paul Hamlyn, London, England, 1969. Horn is a 
British surgeon who spent 15 years in the Chinese medical service. 

30. China Reconstructs: June, 1971. 

31. Hung Chi (Red Flag): August, 1970, as cited in Selections from the China Main- 
land Magazines (hereafter cited as SCMM): 689-90. 

32. Hang Chi (Red Flag): January, 1969. 

33. China Reconstructs: October, 1970. 

34. NCNA: June 25, 1969. 

35. NCNA: July 30, 1970. 

36. Hung Chi (Red Flag): June 1971, as cited in SCMM: 707-708. 



MEDICAL PERSONNEL AND THEIR TRAINING 



Victor W. Sidel, M.D. 



INTRODUCTION 

The material in this paper on the current situation with 
regard to medical personnel and their training in the People's Republic 
of China was gathered during a one month's visit by my wife and me 
in September-October, 1971 as the guests of the Chinese Medical Asso- 
ciation. Although very few statistical data on the current numbers of 
medical workers and their training were available, a wealth of anecdotal 
material was generously shared with us. From the limited statistical 
data, and the large amount of material on individuals, institutions, and 
communities, I have attempted to sketch part of the current picture 
of health manpower in China as we were given it. It should be noted 
that this picture is necessarily incomplete. 

The material on the past history of China's health manpower has 
been much easier to collect from materials published in English. I am 
especially indebted to sources such as Ralph Croizier's Traditional 
Medicine in Modern China, 1 Szeming Sze's China's Health Problems, 2 
and Leo Orleans' Professional Manpower and Education in Communist 
China 3 and Medical Education and Manpower in Communist 
China. 4 Although these historical data are also incomplete, and vary 
from source to source, they have a verifiable quality— in the biblio- 
graphic sense— absent as yet from our data on the current scene. 

Health Manpower in Pre-Liberation China 

The present situation with regard to medical personnel and 
their training in the People's Republic of China, in my view, is impos- 
sible to comprehend without an understanding of the situation prior 
to 1949, the year in which Mao's People's Liberation Army wrested 

153 



154 MEDICINE AND PUBLIC HEALTH 

control of mainland China from the Nationalist forces under Chiang 
Kai-shek. The history of medicine in China during this period is dual, 
with little interchange between the two streams. It is a history on the 
one hand of traditional Chinese medicine (zhongyi), which by legend 
extends back some 30 centuries before the beginning of the Christian 
era, but whose surviving classics were probably written in about the 
third or second century B.C. It is a history on the other hand of the 
introduction of what the Chinese call "Western medicine" (xiyi) . 
with its "scientific" orientation, which began in China with the estab- 
lishment of a dispensary at Macao by Robert Morrison in 1827 and 
the arrival of Peter Parker in Canton as the first full-time medical mis- 
sionary in China in 1835. la 

Traditional Chinese medicine had its "theoretical" basis in such 
concepts as yin and yang, the proper balance of which was felt to be 
necessary to the maintenance of good health, and in ch'i, the vital life 
force. It also had a strong empirical base, in its use of herbal medicine 
and other techniques handed down through the generations. 

The practitioners of Chinese medicine apparently varied greatly in 
their training and in their skills. The absence of any well-defined na- 
tional qualifications for doctors of Chinese medicine prior to Libera- 
tion makes it very difficult to estimate their number. Professor Knud 
Faber, in his study for the League of Nations in 1930, was told that 
there were 1,200,000 practitioners of Chinese medicine and 7,000,000 
"druggists." s When qualifications for doctors of Chinese medicine were 
formally defined by the government of the People's Republic in 1955, 
the total number for the entire People's Republic of China was 
given as 486, 700. 6 It is therefore probably not unreasonable to esti- 
mate the number of "traditional" doctors in 1949 at about 500,000, or 
about one for every 1,100 of the 540 million people in China at that 
time. 

Although the definition of a doctor of Western medicine is considera- 
bly simpler, estimates of their number are almost as varied as the esti- 
mates of traditional doctors. In 1932 the number of registered Western 
doctors was 2,919, 65 per cent of them practicing in the three coastal 
provinces of Kiangsu, Kwangtung, and Chekiang. lc 

By 1937, the same registry included 9,098 physicians, but Croizier 
points out that this is probably an inflated figure because it includes 
every physician registered from 1929 through 1937 without any removal 
of the names of those who had stopped practicing. 10 In 1943, in the 
midst of the "War of Resistance against Japan", Szeming Sze, Secre- 
tary-General of the Chinese Medical Association and Editor of the 
Chinese Medical Journal, estimated that there were 12,000 doctors in 
China. But of these he states: 



MEDICAL PERSONNEL AND THEIR TRAINING 155 

". . . only 60% of the total are duly qualified doctors, the balance being 
apprentice-trained practitioners who were permitted to register up to 1937; 

(b) 75% are concentrated in the main ports of the six coastal provinces: 

(c) 92% are under the age of 50, and 67% under the age of 40, showing the 
relatively recent development of medical schools. 28 " 

Chinese estimates of the number of doctors of Western medicine in 
China at the time of Liberation in 1949 vary from 20,000 to 41,400. 4,) 
One Western estimate is as low as 1 0,000. ld Thus the Western-doctor-to- 
population ratio in 1949 may have been as little as one doctor for every 
45,000 people or as "high" as one doctor for every 14,000. In either case, 
the number is extremely low, and it seems clear that the only doctors to 
whom the vast majority of the peasants in the rural areas, and of the 
poor people of the cities, had access were the doctors of traditional med- 
icine. 

Efforts had been made, of course, during the years prior to 1949 to 
increase the number of health personnel of the "Western" type. The 
bulk of the effort, however, went into the training of physicians follow- 
ing European or American models. Missionary medical schools sup- 
ported by groups in the United States, Germany, France, and England 
were developed and the Peking Union Medical College was founded 
and supported through the Rockefeller Foundation and its affiliate, the 
China Medical Board. Although some observers called for new forms of 
health personnel and new forms of training— notably Professor Faber, 
whose League of Nations report called for "Special Medical Schools" 
to increase the number of physicians trained to 5000 per year (com- 
pared to less than 200 per year being graduated in 1929), le and Dr. John 
Grant, who wrote of rural health workers working through rural health 
stations 7 — relatively little came of these suggestions. Even under the 
pressure of the war against Japan, with its considerable unrestricted aid 
from the United States, the "Emergency Medical Services Training 
Schools" did little to meet the need for some 30,000 medical officers. 16 
The limited medical education facilities and the limited production of 
"scientific" doctors, in short, followed Western models which seem, 
both at the time and in retrospect, completely inappropriate, as well as 
inadequate, to meet the massive needs of China's people. 

Health Manpower From Liberation to Cultural Revolution 

At the time of Liberation a vast effort was undertaken to 
meet the needs. It had been a tradition in the People's Liberation Army 
that in each liberated village medical services would be provided insofar 
as possible by Army personnel, and this tradition led to a prompt em- 
phasis on medical education by the new government. Although the 
data on medical care personnel and their education vary, it is possible 



156 MEDICINE AND PUBLIC HEALTH 

to find some official figures for the years 1949 to 1958. Since that time 
data have been less easily available; those which could be found 
through 1968 have been gathered and cogently integrated and analyzed 
by Orleans. 1 He estimates that at the end of 1966 there were about 
150,000 doctors of Western medicine in China, a ratio of one doctor 
for every 5,000 people.* 

This almost incredible increase in number of doctors— over 100,000 
trained in 17 years— was accomplished through major restructuring of 
China's medical schools. This was largely done using models provided 
by Soviet advisors, which led to medical schools independent of univer- 
sities and divided into "faculties" of therapeutics (often further subdi- 
vided into a faculty of pediatrics), public health, pharmacy, and stoma- 
tology. The basic medical school course was five or six years, with one 
school— the China Medical College, successor to the Peking Union Med- 
ical College— having a course of eight years and training mainly teach- 
ers and researchers. Students were generally required to complete senior 
middle school, the rough equivalent of our high school. Testimony 
from Westerners visiting China in the late 1950's and early 1960's sug- 
gests that this was indeed the basic pattern. In addition there was evi- 
dence that some schools were providing less than "standard" training 
but whose graduates were still to be considered by the authorities as 
"regular doctors" (as contrasted with the assistant doctors described 
below). Theodore Fox, editor of the Lancet, wrote in 1957, for exam- 
ple, of the difficulty of dealing with an annual class of 400-600 and of 
shortening the curriculum: "Lasting harm is done to a profession, and 
the people it serves, by introducing new members who have not had a 
proper basic training . . . Much useful work can be done by people 
without a good basic training, but they should not be called doctors. In 
China, I would say, entry to the over-crowded medical colleges should 
be further curtailed, and the need for more 'pairs of hands' in medicine 
should be met by training more feldshers . . ." 9 

Be that as it may, there clearly was an increase in the number of 
medical schools and a vast increase in the class size in each. Again esti- 
mates vary, but in 1962 there were said to be about 60 medical schools 
teaching Western medicine and ten teaching traditional Chinese medi- 
cine. As an example of the accomplishments in one of these schools, we 
were told, that, in the First Medical College in Peking in the 37 years 
from 1912 (the year of its founding) to 1949, there had been only 1,049 
graduates. In the 22 years between 1949 and 1971, there were 10,000 



*To show the range of estimates, the Dean of Faculty of Medicine at the University 
of New South Wales, Australia, in an article in 1969 gave a ratio of one doctor 
per 22,000 inhabitants, unquestionably too low. s The point, of course, is that truh 
reliable figures are as yet unavailable. 



MEDICAL PERSONNEL AND THEIR TRAINING 157 

graduates. Although it is probable that this number includes some 
pharmacists and some nurses as well as doctors, the increase in gradu- 
ates is impressive. 

With regard to the training of doctors of Chinese medicine during 
this period, it appears that both the apprenticeship and the medical 
school methods were used. Orleans estimates that about five or six thou- 
sand doctors of Chinese medicine were graduated annually. It is diffi- 
cult to know how to combine the figures on these graduates, who may 
have numbered as many as 75,000 during the 17-year period in ques- 
tion, with our estimate of a half million traditional Chinese doctors at 
the start of the period. It is probably best simply to assume that the new 
graduates did little more than replace those lost by death and retire- 
ment, leaving the etimated total at about 500,000 in 1965. 

Great efforts were made during this period to integrate the doctors of 
traditional Chinese medicine with the doctors of Western medicine and 
to make better use of the traditional doctors. This movement began in 
the early 1950's with a directive by Chairman Mao Tse-tung that West- 
ern medicine was to be combined as much as possible with Chinese 
medicine. Mao has stated, for example, that "Chinese medicine and 
pharmacology are a great treasure-house; efforts should be made to ex- 
plore them and raise them to a higher level." 10 

There were many reasons for the emphasis on Chinese medicine. The 
first, of course, was that most, if not all, Chinese are convinced of the 
efficacy of many of the methods of Chinese medicine. It was certainly 
true that the rural people, especially, had great faith in their traditional 
doctors and would at times refuse to accept Western practice even when 
it was available. On more ideological grounds, Croizier attributes the 
emphasis on Chinese medicine to "cultural nationalism," which has led 
to stress on "Chinese painting," "Chinese music," and "Chinese 
drama." lf A more pragmatic aspect— possibly the most important, since 
the Chinese are unashamedly pragmatic in their application of ideology 
—was the fact that the only practitioners available to most people in the 
rural areas were the traditional doctors and it was therefore felt to be 
important that they be brought into close contact with Western medi- 
cine rather than remaining isolated from it. In the period following 
Liberation, this combination indeed began to be accomplished— for 
example, the Chinese Medical Association, which prior to 1949 had 
been open only to doctors of Western medicine, began to open its doors 
to some traditional Chinese physicians— but the integration appears to 
have met with incomplete success. 

Another major source of medical manpower, again following the So- 
viet model, was the development of "middle medical schools." One set 
of estimates is that there were 170 such schools in 1957, 200 in 1964 and 



158 MEDICINE AND PUBLIC HEALTH 

230 in 1965. 4c These schools accepted students after junior middle 
school, equivalent to our junior high school, and offered them courses 
of about three years. They might graduate as physicians' assistants 
(comparable in many ways, insofar as I can tell, to the Soviet feldsh- 
ers), nurses, midwives, pharmacists, and radiology or laboratory tech- 
nicians. Their description bears a startling resemblence to the Soviet 
"middle medical schools," which train feldshers, nurses, midwives, 
pharmacists, and radiology or laboratory technicians, as well as "den- 
tists", in a program of about three years following the equivalent of 
junior high school graduation. 

Orleans estimates that at the end of 1966 there were approximately 
172,000 assistant doctors, 186,000 nurses, 42,000 midwives, and 100,000 
pharmacists. 4 * 1 In addition, he estimates that among the graduates of 
"higher medical education", of which the physician is the most numer- 
ous example, there were at the end of 1966 some 30,000 dentists (whom 
the Soviets would at this level of training call stomatologists rather 
than dentists) and 20,000 pharmacists (or, to distinguish them from 
the middle medical school pharmacy graduates, "pharmacologists"). 
Overall, then, an informed guess on the medical manpower in the Peo- 
ple's Republic of China at the time of the start of the Cultural Revolu- 
tion in 1965 would appear to be: 









Number 


per 


100,000 


People per 


Type of Personnel 


Number 


Pop 


mlation 


Practitioner 


Doctors of Western 


Medicine 


150,000 




21 




5,000 


Doctors of Chinese 


Medicine 


500,000 




70 




1,500 


Stomatologists 




30,000 




4 




25,000 


"Pharmacologists" 




20,000 




3 




36,000 


Assistant doctors 




170,000 




23 




4,300 


Nurses 




185,000 




26 




3,900 


Midwives 




40,000 




6 




18,000 


Pharmacists 




100,000 




14 




7.000 



Although comparison with the United States has no direct signifi- 
cance since the job definitions, the medical problems, and medical care 
organization are so different, it may be helpful in understanding these 
data to note that in the United States in 1970, for a population of some 
210 million, there were approximately 335,000 physicians (158 per 
100,000, or one for each 630 people), 93,000 dentists (46 per 100,000, or 
one per 2,200) and 700,000 nurses (345 per 100,000, or one per 290). 

Health Manpower Post-Cultural Revolution 

Formal medical education was almost entirely discontinued 
during the height of the Cultural Revolution. Those already in medical 



MEDICAL PERSONNEL AND THEIR TRAINING 159 

school were apparently given some accelerated training, were graduated, 
and assigned to medical services in the countryside. Other major new 
efforts were made to re-distribute existing health manpower, which de- 
spite previous attempts were still said to be concentrated in urban areas. 

In 1965, as one of the earliest acts of the Revolution, Chairman Mao 
issued his "June 26th Directive": "In health and medical work, put the 
stress on the rural areas." Doctors in urban hospitals, for example, are 
now required to spend periods of time ranging from three months to 
one year on rotation in rural areas; some one-third of urban physicians 
are on such assignment at any given time. If the doctor volunteers to 
spend a period of time longer than a year in the country-side, he may 
take his family with him; for shorter periods, the doctor's family re- 
mains in the city. The role of the urban doctors in the rural area is not 
only to provide medical services directly and to train indigenous rural 
personnel (such as the "barefoot doctors") but also for the urban doc- 
tors to be "re-educated" into the needs and problems of the people in 
the rural areas. 

An example of this type of rotation was given us by Dr. Hsu Chia-yu, 
the Deputy Chief of Internal Medicine at the "East is Red" Hospital in 
Shanghai and our interpreter while we were in China. Since 1965 Dr. 
Hsu has had three rotations into a rural county on the outskirts of 
Shanghai: one for 3 months, one for 6 months, and one for a year. Dur- 
ing one of these tours Dr. Hsu's task was training barefoot doctors in a 
county hospital, and then returning with them to their commune to 
provide on-the-job supervision and training. As Dr. Hsu described it, 
he lived with a barefoot doctor and his family, sleeping at night in the 
same bed and using the same pillow as the barefoot doctor. He told us 
that this had been quite difficult for him to do because he had been 
raised in Shanghai and had never shared a pillow with anyone before. 
Dr. Hsu described how he and the barefoot doctor would talk before 
going to sleep, both of the patients they had seen during the day and of 
their hopes and goals for their society. 

Although there were precedents for its development prior to 1965 — 
and even some precedents prior to 1949— the Cultural Revolution 
brought rapid expansion of new forms of health manpower, very differ- 
ent from the "regular" doctors and the "middle" medical personnel. 
These new forms of health workers are not thought of primarily as 
health workers at all; they are counted in the Chinese statistics— and ap- 
parently think of themselves— primarily as agricultural workers (the 
"barefoot doctors"), production workers (the "worker doctors"), or 
housewives or retired people (the "Red Guard doctors"). None of these 
workers is said to be paid specifically for his medical work; he simply 
does not lose work points (in the case of the barefoot doctor) or salary 



160 MEDICINE AND PUBLIC HEALTH 

(in the case of the worker doctor) for the time he spends doing his 
health work. In general this effort seemed to absorb about half of his 
time, the exact amount depending on the work load of the institution.* 

The description of the barefoot doctor's duties varied from area to 
area but there were many common features. In general, they have re- 
sponsibility for environmental sanitation, for immunization, for first 
aid, and for portions of personal primary medical care and post-illness 
follow-up. 

With regard to environmental sanitation, the barefoot doctor has re- 
sponsibility, for example, for the proper disposal and later use of 
human feces as fertilizer, for the purity of the drinking water, and for 
the control of and campaigns against "pests". Many of the actual sanita- 
tion tasks are usually carried out by more junior "health workers" 
whom the barefoot doctor trains and supervises. Immunizations are an 
important responsibility of the barefoot doctor, but again are often ac- 
tually performed by the "health workers", who do their work during 
lunch hours and "leisure time". 

Health education and elements of primary medical care are other im- 
portant parts of the task of the barefoot doctor. The barefoot doctor is 
also readily available for medical emergencies since he often works in 
the fields with his patients and lives among them. He is said to be 
skilled in first aid and in the treatment of "minor and common ill- 
nesses." Perhaps most important, his fellow workers know him well and 
trust him. 

Some idea of the range of what the barefoot doctor is supposed to 
know is provided by a Barefoot Doctor Handbook, 12 published in 
Hunan Province but apparently widely available in China. Excerpts 
from the Table of Contents of the Handbook are shown in Table 1. 
The presence of diseases in the Table do not necessarily reflect their in- 
cidence and prevalence; rickets, for example, was a most important dis- 
ease in China in the past and is discussed in the Handbook, but we 
were told it has been almost entirely eliminated with the improvement 
of dietary conditions. Another, perhaps more direct, measure of what 
the barefoot doctor does is the contents of his medical bag. An overall 
list of what the barefoot doctor's bag might contain— provided us by the 
Chinese Medical Association— is shown in Table 2; the items which we 
actually found in a barefoot doctor's bag in a commune near Shanghai 
and in a worker doctor's cabinet in a factory in Peking are noted. Care- 
ful review of these items with the barefoot doctor and worker doctor 
showed a remarkably detailed knowledge of the nature of the medica- 



*A detailed description of the barefoot doctors and their training is presented in 
the New England Journal of Medicine. 11 



MEDICAL PERSONNEL AND THEIR TRAINING 161 

tions under their control, the indications and contraindications for the 
medicine, and their potential for adverse reactions. 

The barefoot doctor receives the usual income of an agricultural 
worker, perhaps 300 yuan ($120) per year. The commune worker's in- 
come depends on the total income of his commune and the number of 
"work points" which he collects. The barefoot doctor generates work 
points for himself by doing medical work just as though he was doing 
agricultural work during the same period. 

The explanation of the method of payment given us in 1971 differed 
somewhat from the description given in China's Medicine in 1968. 13 

"The barefoot doctor of the Dongbin brigade, which is well off, earned 300 
yuan. Of this, 100 yuan came from doing farm work, the rest was paid him 
by the brigade for his medical services. Actually, however, 125 of this re- 
maining amount was made up by what he himself turned over to the brigade 
in the way of fees for making home calls, giving injections (5 fen each) and 
delivering babies (3 yuan each). Thus what the brigade actually paid out 
was only 75 yuan." 

These fee-for-service payments, and salary to the barefoot doctor spe- 
cifically for medical services, are apparently being de-emphasized by the 
development of "collective medical services" in the communes. As it 
was explained to us, the commune collects a small annual premium 
(about 1 yuan) from each commune member; the medical collective, 
with a subsidy from general commune funds if needed, then covers all 
of the medical expenses for the member over the course of the year. 

The worker doctor is analogous to the barefoot doctor, but works in 
the urban factories. As in the recruitment of the barefoot doctor from 
among the commune members, a factory worker is chosen by his fellow 
workers to become the worker doctor in their workshop. The bulk of 
his health work is spent on health education and on preventive medi- 
cine. He teaches his fellow workers about the early recognition of cer- 
tain diseases and ensures that the immunizations of the workers in his 
shop are up-to-date. He treats "common illnesses" right in the shop, 
most often by the use of acupuncture. The medications which we found 
in one worker doctor's medicine cabinet are also shown in Table 2. 
Like the barefoot doctor, he seemed to have an accurate knowledge of 
these medications under his control. 

The Red Guard doctor serves in the lane and neighborhood health 
stations. She is usually a housewife; all the Red Guard doctors live in 
the neighborhood which their lane health center serves, usually no 
more than 300 yards from the station. 

The major tasks of the Red Guard doctors relate to preventive medi- 
cine. They are responsible for the immunizations in the lane, which 
they do themselves, and the maintenance of records and statistics on the 



162 MEDICINE AND PUBLIC HEALTH 

children's immunizations. The Red Guard doctor also helps organize 
the people through the Great Patriotic Health Movements to ensure 
sanitation and prevent disease. 

Another important function of the Red Guard doctors is the dissemi- 
nation of birth control information. Birth control data are gathered by 
the Red Guard doctors during monthly visits to each woman in the 
area covered by the health station. As a result of this intensive effort, 
the birth rate in the cities has apparently declined markedly. 

Although to my knowledge there are no data available on the num- 
bers of current health manpower in China, during our visit in October, 
1971 we were given health manpower figures for the Peking and Shang- 
hai independent municipalities: 







Number per 100,000 


People per 




Number 


Population 


Practitioner 


Shanghai (10 million people in 








10 urban districts and 10 








rural counties) 








Doctors of Western medicine 


9,000 


90 


1,000 


Doctors of Chinese medicine 


3,500 


35 


2,900 


Assistant (middle-grade) doc- 


4,000 


40 


2,500 


tors 








Nurses 


15,000 


150 


700 


Technicians, pharmacists, etc. 


14,000 


140 


700 


Peking (7 million people in 9 








urban districts and 9 rural 








counties) 








Doctors of Western medicine 


10,000 


100 


700 


Doctors of Chinese medicine 


2,000 


20 


3,500 


Assistant (middle-grade) doc- 


5,000 


50 


1,400 


tors 








Nurses 


11,000 


110 


600 


Technicians, pharmacists, etc. 


8,000 


80 


900 



These figures do not include barefoot doctors, worker doctors, or Red 
Guard Doctors, who are not considered "health" manpower. There are 
now said to be "over a million" barefoot doctors in China. 

Training of Health Personnel 

In the aftermath of the Cultural Revolution, all institutions 
of any significant size in China including educational institutions are 
being run by "Revolutionary Committees". These Committees generally 
consist of a "three-in-one" combination of one or two representatives 
of China's Army (the "People's Liberation Army") , one or more 
cadres (political workers, usually but not necessarily members of the 
Communist Party) , and representatives of the "mass." In the case of 



MEDICAL PERSONNEL AND THEIR TRAINING 163 

a factory, the "mass" are its workers; in the case of a commune, its 
peasants; in the case of a hospital, its nurses, doctors, and other work- 
ers; and in the case of a medical school, its faculty and— in at least 
one of the schools we visited— its students. The Revolutionary Commit- 
tee sets the policies and directs their implementation for the institu- 
tion, within guidelines set out by higher policy-making groups on a 
national and local level. 

The Cultural Revolution had an enormous impact on education. 
The old educational system was severely criticized. For example, the 
Revolutionary Committee of the Shanghai First Medical College in 
1968 wrote in China's Medicine: 

". . . the students, once they entered a medical college, were long exposed 
to the poison of 'making one's own way and achieving fame, wealth and 
position' by scrambling up the ladder rung by rung: assistant— lecturer- 
professor, or resident— chief resident— visiting doctor— department head— di- 
rector. Under the influence of the bourgeois idea of 'one who has technique 
has all', not a few students preferred indolence and ease, had a hankering 
for city life and big hospitals and, regarding themselves as 'elite,' refused 
to go to the countryside and mountainous regions. With such notions in 
their heads, how would they possibly serve the workers, peasants and 
soldiers?" 1S 

Not only were the attitudes developed felt to be inappropriate, but 
the curriculum was said to be "decayed and timeworn" and "copied 
from capitalist and revisionist countries (i.e., the United States and 
Soviet Union) ." 

". . . The curriculum required students to study as long as six or even eight 
years, but after graduation they were unable to treat independently even the 
most frequently encountered diseases. Leaving the big hospital, with its 
laboratories and modern equipment, they found themselves at their wits' 
end. In the course of six years, three-fourths of the time was spent studying 
textbooks and reciting abstract theories . . . The preclinical work that 
the students could find no effective use for, the supposedly basic theories 
which had been drilled into them. Education in the medical colleges over 
the years was carried out after the fashion of stuffing and fattening Peking 
ducks. The students memorized the subjects for the examination, and once 
their ordeals were over, all was well and forgotten." 13 

Higher education was therefore changed following the Cultural Rev- 
olution both in relation to how students are chosen and to how and 
what they are taught. In the past few years students have left school 
after completion of junior middle school, at about age 16. They then go 
off for at least two years, and more likely three years, to work in a com- 
mune or factory. At the end of that period of time, if they are chosen by 
their fellow workers, they are admitted to universities, professional 
schools or technical schools. The criteria by which they are chosen by 
their peers include not only intellectual accomplishments, but more im- 



164 MEDICINE AND PUBLIC HEALTH 

portantly the attitudes and principles they have expressed and live by 
during their period of work. As we were repeatedly told, it is a person's 
"politics" and his "attitude toward the people" rather than how bril- 
liant he is which determine whether he will be a good doctor or other 
kind of professional. 

With regard to style and content of education, not only was the cur- 
riculum generally shortened in the wake of the Cultural Revolution but 
the practical content was markedly increased relative to the theoretical 
content. Also, periods of direct work were included in all programs. 
Thus a student studying physics now spends some of this time in facto- 
ries learning how physics can be helpful in production and a student of 
biology spends time on the communes learning how biology can be 
helpful in agriculture. 

Medical Schools* 

The most immediate effect on Chinese medical schools was 
that they admitted no new classes for three years. In 1969, the schools 
began to resume their teaching, but on an experimental basis. At the 
Dr. Sun Yat-Sen Medical School in Canton, for example, a class of 65 
students was admitted on May 7, 1969 and graduated after only one 
year of training. We were told, however, they are not felt to be "fully" 
educated doctors. On May 6, 1970 a new class of 600 students was ad- 
mitted to the Sun Yat-Sen School; of the 600 approximately 350 are 
male and 250 are female. These students will graduate after two years 
of training. Another class of 600 students was admitted in October, 
1970 and it is anticipated they will graduate in three years. In 1972 
another 600 students will be admitted. 

At the First Peking Medical College, after a three-year hiatus, 600 
students were enrolled in December, 1970 and the school expects to en- 
roll 1,000 students in 1972 and every year thereafter. In Shanghai, the 
First and Second Shanghai Medical Schools were in October 1971 just 
in the process of admitting their first classes following the Cultural Re- 
volution. 

Since choice of entrants into medical schools lies primarily with their 
fellow-workers in the communes or factories, not surprisingly those who 
have indicated interest and skill in the caring roles, such as barefoot 
doctors and nurses, will often be the ones chosen. Once a student is cho- 
sen by his fellow workers and recommended by the administration of 
the factory or commune, his entrance into medical school must also be 
approved by the administration of the medical school. The criteria 
used are: (1) ideological commitment; (2) academic ability; and (3) 



*This material was in part presented in The New Physician. 1 



MEDICAL PERSONNEL AND THEIR TRAINING 165 

physical fitness. We were told that medical schools rarely exercise a veto 
over those chosen by their fellow-workers. 

The length of medical training has been considerably shortened. 
During the years from 1949 to 1965, medical education in general re- 
quired five years with a sixth year of internship. Although each of 
China's medical schools is developing its own experimental curriculum 
since the Cultural Revolution, it appears that none are generally 
planned to be longer than about three years. 

The two-year curriculum in Canton, which is now underway, started 
with a three-month combination course in anatomy, histology, biochem- 
istry, and physiology. This was followed by a three-month period in 
which groups of about 30 students went to the countryside with three 
teachers. The students then returned to the campus in Canton where 
they took a six-month combined course which included pharmacology, 
parasitology, pathology, and physical and laboratory diagnosis. For their 
second and final year, it is planned that the students will have four 
months in internal medicine and pediatrics, four months in surgery 
and the surgical specialties (including ten days of ophthalmology) and 
then four months back in the countryside to practice under supervision 
what they have learned. They will also have courses in traditional 
Chinese medicine and in Mao Tse-tung thought. 

The pattern for a three-year program was presented to us in Peking.* 
The first course included anatomy, physiology, biochemistry and histol- 
ogy. This course lasted about four months and was followed by another 
four months' course which included bacteriology, parasitology, pharma- 
cology, pathology, laboratory diagnosis and physical diagnosis. To com- 
plete the first year, and at the end of each succeeding year, there will be 
two months of physical training, military training, and manual work, 
and one month of vacation. Also included in the first year is political 
education and training in aspects of traditional Chinese medicine. 

During the first six months of the second year, it is planned that the 
students will begin their clinical training by taking courses in internal 
medicine, pediatrics, surgery, obstetrics and gynecology. For the last 
three months of the second year, the first six months of the third year, 
the students will go into the countryside with their teachers to learn 
practical clinical medicine, public health and epidemiology. They will 
also learn and practice traditional and herb medicine, and with their 
teachers will do physical labor in the communes in which they are work- 
ing. During the last three months of their third and final year, the stu- 
dents will return to a teaching hospital in Peking where they will con- 



*This presentation was also the basis for Dimond's description of the current 
curriculum at the First Peking Medical School. 15 



166 MEDICINE AND PUBLIC HEALTH 

solidate what they have learned in the countryside through lectures, 
discussions, ward rounds, and clinical conferences. 

When we asked how they had managed to compress material, which 
had previously taken six years, into three years, we were told that it was 
done by eliminating the irrelevant and the redundant, by combining 
the theoretical with the practical, and by using the "three-in-one" prin- 
ciple of: teachers teach students; students teach teachers; and students 
teach students. New methods of teaching are being tried. We were told 
that now, in contrast to the past, students are encouraged to be much 
more questioning of what they are taught and to participate much more 
in the educational process. 

There are said to be no grades and no competition. Examinations are 
for the purpose of letting the students know what they have not com- 
pletely understood, and of letting the teachers know what they are not 
teaching successfully. Grades are not given because classes are small 
enough and the teachers are able to get to know the students well and 
know how they are doing. 

There is apparently almost no attrition for academic reasons. When 
students fail to finish their medical education because of ill health, they 
are encouraged to return when they are well. There is no tuition, and 
students are paid a modest stipend that is apparently sufficient for only 
a most modest standard of living. 

Training of the Barefoot Doctor and His Analogue 

In the same way that much of the work of the barefoot 
doctor seems to vary from place to place in China, so too does the pat- 
tern of his education. The most frequent pattern appears to be a 
three-month period of formal training, either in the county hospital or 
in the commune hospital, that is fairly evenly divided between theoreti- 
cal and practical work. As in the education of regular doctors, there 
are said to be no grades and no competition between the students. The 
three-month training is followed by a variable period of on-the-job 
supervised experience. As seems to be common throughout most job 
requirements in present-day China, there appears to be little emphasis 
on a specific credential or certificate which has been earned, but rather 
on the skills which the individual can demonstrate in a particular job 
situation. 

The formal training of the worker doctor seems in general to be 
shorter than that of the barefoot doctor, usually about a month. Con- 
tinuing on-the-job supervision and training is considered much more 
important. One worker doctor we talked with has his continuing train- 
ing by spending an entire day every two weeks in the health clinic of his 



MEDICAL PERSONNEL AND THEIR TRAINING 167 

factory. He said that when his production schedule makes it possible he 
sometimes spends an entire week in the health clinic. 

In the formal training period of the Red Guard doctor, which lasts 
only ten days, the emphasis is on allaying the fears of the housewives 
that they cannot do the medical work. The Red Guard doctors also re- 
ceive continuing training, by working closely with the doctor who is as- 
signed to the health station. A period each day is set aside for reviewing 
their medical activities and discussing the works of Chairman Mao and 
its applicability to their own work. In one specific case, the Red Guard 
doctors from the 23 lane health stations supervised by a district health 
center in Peking get together weekly for lectures and exchange of expe- 
rience. 

Summary 

In the course of 22 years the People's Republic of China 
has managed to make almost incredible progress in the training and 
distribution of health care personnel. Starting with grossly inadequate 
numbers, they have trained large numbers of Western-type physicians, 
have trained "middle medical workers" along the lines of Soviet models, 
and have developed new types of health workers who help bridge the 
gap between "professional" and "para-professional" and help fill the 
gaps in availability of medical personnel. Especially since the Cultural 
Revolution, there have been great changes in distribution of medical 
workers, with urban personnel being rotated for periods up to a year 
or moving out for longer periods into the rural areas. 

The nature of the training of medical personnel has also changed 
markedly since the Cultural Revolution. These changes include a shift 
in the criteria for admission from academic prowess toward ideologic 
commitment, a shortening and restructuring of the curriculum, an em- 
phasis on the practical compared to the theoretical, and an increased 
integration of training in the techniques of traditional Chinese medi- 
cine into the education of Western-type personnel. Above all, there ap- 
pears to be a firm commitment to the development of human potential 
and to the importance of human services, both in the selection and 
training of medical personnel and in their relationship to their patients 
and communities. 

TABLE I 

Excerpts from the Table of Contents of the Barefoot Doctor's Handbook 

Chapter I Recognition of the Human Body 
Section 1— Perceptive Organ Systems 

Eye; Ear; Nose; Tongue; Throat; Pharynx 
Section 2— Histology of the Skin 



158 MEDICINE AND PUBLIC HEALTH 

Section 3— Nervous System 

Cranial nerves; Spinal cord and spinal nerves; Autonomic nerves; Reflexes 
Section 4— Endocrine System 

Thyroid gland; Adrenals: Insulin; Pituitary; Gonads 
Section 5— Motor System . . . 
Section 6— Circulatory System . . . 
Section 7— Respiratory System . . . 
Section 8— Digestive System . . . 
Section 9— Urinary System . . . 
Section 10— Reproductive System . . . 

Section 11— Characteristic of the Different Systems in Children 
Section 12— Perception of the Human Body hy Traditional Methods . . . 

Chapter II Common Sense of Hygiene 
Section 1— The Patriotic Health Movement 

Water hygiene; Management of night soil; Food hygiene 
Section 2— Hygiene in Agricultural and Industrial Production . . . 
Section 3— Wiping out Pests 

Eradication of flies, mosquitoes, rats, etc. 
Section 4— Personal Hygiene 

Oral hygiene; Skin and clothing 

Chapter III Some Knowledge of Diagnosis 
Section 1— How to Understand Disease 

History-taking; Inspection; Auscultation; Palpation; Tendon reflexes 
Section 2— How to Analyze the Etiology of Disease 

Constitutional factors (temperament, body build, etc.); External factors (physical, 
biological, seasonal, etc.) 
Section 3— How to Differentiate the Syndromes of Traditional Medicine . . . 

Chapter IV Some Knowledge of Treatment 

Section 1— Traditional and Herb Medicinal Therapy 
Section 2— Empirical Methods Used Among the Mass . . . 
Section 3— New Traditional Methods 

"New acupuncture;" Moxibustion; etc. 
Section 4— General Techniques 

Dressings; Incision and drainage; Local anesthesia; Gastric lavage, External 
cardiac massage, Ligation of vas deferens, etc. 

Chapter V Birth Control 

Section 1— Meaning of Family Planning 

Section 2— Encouragement of Late Marriage 

Section 3— Contraception 

Traditional; Condoms; Oral contraceptives 

Section 4— Permanent Sterilization . . . 

Section 5— Artificial Abortion 

Section 6— Modern Methods of Delivery 
Chapter VI Diagnosis and Treatment of Common diseases 

Section 1— Rescue and Cure of the Wounded in Warfare . . . 

Section 2— Emergencies 

Drowning; Electric shock; Burns, Snake bite; etc. 



MEDICAL PERSONNEL AND THEIR TRAINING 169 

Section 3— Common Symptoms 

Fever; Jaundice; Edema; Epistaxis; Hematuria; etc. 
Section 4— Common Infectious Diseases 

Influenza; Measles; Varicella; Pertussis; etc. 
Section 5— Parasitic Diseases 

Schistosomiasis; Filariasis; Hookworm; etc. 
Section 6— Internal Medicine 

Upper respiratory infection; Asthma, Cirrhosis, Migraine, etc. 
Section 7— Surgical and Traumatic Disease 

Fracture. Dislocations; Sprains; Carbuncles; etc. 
Section 8— Obstetric and Gynecologic Disease 

Dysmenorrhea; Leukorrhea; Mastitis; etc. 
Section 9— Pediatric Disease 

Rickets; Infantile diarrhea; Thrush; "Summer fever"; etc. 
Section 10— ENT Disease (Including Eye and Stomatology) 

Rhinitis; Sinusitis; Toothache, Keratitis; etc. 

Chapter VII Traditional and Herb Medicines 
Section 1— General Information 
Section 2— Commonly Used Medicines 

Individual listings of 533 traditional medicines. 

TABLE II 

Standard List of Items Included in a Barefoot Doctor's Bag 

Medications 

Adona ampoules 

Adrenalin ampoules 

Aminophyllin tablets and ampoules ' 

Ammonium Chloride tablets and solution - 

Analgin tablets and ampoules 

A.P.C. or P.P.C. tablets (aspirin-Phenacetin-caffeine) 1,a 

Atropine tablets 

Belladonna Extract tablets 12 

Berberine (a traditional Chinese medicine with antibiotic properties) tablets 1 

Brown's Mixture tablets and Liquid 1 

Butazolidin (phenylbutazone) tablets 

Caffeine Sodium Benzoate ampoules 

Chloromycetin (chloramphenicol) ampoules and capsules 

Chlorpheniramine tablets 2 

Chlorpromazine tablets and ampoules '•• 

Chlothamine tablets 

Coramine (nikethamide) ampoules 

D.C.T. tablets 

Dolantine ampoules 

D.P.P. tablets 

Ephedrine Sulfate tablets 

Furadantin (nitrofurantoin) tablets - 

Furazolidone tablets 1,a 

Gastropin (a medication for peptic ulcer) tablets 2 

Lobodura tablets 

Luminal (phenobarbital) tablets ' 



170 MEDICINE AND PUBLIC HEALTH 

Paperazine tablets 

Penicillin, crystalline 

Penicillin, procaine 

Phenergan (promethazine) tablets 

Phenolax (a laxative) tablets *•* 

Probanthine (propantheline bromide) tablets 

Reserpine tablets 

S.M.2 tablets 

Soda Bicarbonate tablets 

S.T. tablets 

Sulfadiazine tablets and ampoules ' 

Sulfaguanidine tablets 

Sulfamethoxypyridazine tablets 1,s 

Syntomycin capsules 

Terramycin (oxytetracycline) tablets 

Tetracycline tablets ' 

Valium (diazepam) tablets ' 

Violactyl (lactobacillus) tablets ' 

Vitamin Bl tablets 1 

Vitamin B2 tablets 2 

Vitamin C tablets 2 

Vitamin K tablets 2 

Vitamin U tablets' 

Yeast tablets * 

Topical Agents 
Alcohol ' 

Boric Acid Ointment 
"Eye Drops" 
"Eye Ointment" 
Gentian Violet ] 
Iodine Tincture 
Mercurochrome J 
"Nose Drops" 
"Sulfa Ointment" 

Traditional and Herb Medicines 

Pills and tablets. Type depends on the individual commune or other site. Examples 
include antipyretics, 1 ' 2 antitussives, 12 antispasmodics, 2 and medication for dysmenor- 
rhea. 2 

Equipment 

Acupuncture Needles 1 

Adhesive Tape 

Bandages and Gauze 

Bowl (for changing dressings) 

Cotton Sponges 

Cotton Swabs J 

Cups (for drinking) 

Forceps 

Fountain Pen 

Hypodermic Needles " 

Manometer (sphygmomanometer) 



MEDICAL PERSONNEL AND THEIR TRAINING 171 

Notebook for Records 

Paper Bag 

Rubber Tubing 

Scissors 

Syringes, 2 cc. and 5 cc. 1 

Thermometer, oral and rectal i 

1 Items found in the bag of a barefoot doctor in a commune outside Peking. 

2 Items found in the cabinet of a worker doctor in a Peking factory. 



172 MEDICINE AND PUBLIC HEALTH 

REFERENCES 

1. Croizier R. C: Traditional Medicine in Modern China. Howard University Press, 
1968. a) p. 37; b) p. 266; c) p. 250; d) p. 157; e) p. 54; f) p. 4. 

2. Sze S.: China's Health Problems. Washington, D.C., Chinese Medical Assn, 1943. 
a) p. 18. 

3. Orleans L. A.: "Professional Manpower and Education in Communist China." 
NSF 61-3, National Science Foundation, 1961. 

4. Orleans L. A.: Medical Education and Manpower in Communist China. Aspects 
of Chinese Education, edited by CT. Hu. New York, Teacher's College Press, 
Columbia University, 1969. a) p. 31; b) p. 21; c) p. 34; d) p. 37. 

5. Faber K.: Report on Medical Schools in China. Geneva: League of Nations. 
Health Organizations, 1931, cited by Croizier . lb 

6. Jen-min Shou-tse (People's Handbook (Peking)), 1957, p. 608, cited by Orleans/ 4 " 

7. Seipp C. (ed.) : Health Care for the Community: Selected Papers of Dr. John Ii. 
Grant. Baltimore, The Johns Hopkins Press, 1963. 

8. Rundle F. F.: "Community distribution of doctors as a challenge to medical edu- 
cation and training." Med J Australia : 1064-1065, May 23, 1970. 

9. Fox T.: "The new China: some medical impressions." Lancet 2:935-939, 995-999, 
1053-1057, 1957. 

10. "China creates acupunctural anesthesia." Peking Review 14 (33):7-ll. August 
13, 1971. 

11. Sidel V. W.: "The Barefoot Doctors of the People's Republic of China." A' Engl 
J Med (in press). 

12. "Human Chinese Medical and Pharmaceutical Institute Revolutionary Com- 
mittee." Chijiao Yisheng Shou-tse (Barefoot Doctor Handbook). Hunan People's 
Publishers, 1970. 

13. "Revolutionary Committee of the Shanghai First Medical College: Medical edu- 
cation must be transformed on the basis of Mao Tse-tung's thought." China's 
Medicine (#3): 159-163, March, 1968. 

14. Sidel V. W.: "Serve the People: Medical Education in the People's Republic of 
China." New Physician (in press). 

15. Dimond E. G: "Medical education and care in People's Republic of China." 
/ Amer Med Assn 218:1552-1557, 1971. 



THE ACADEMY OF MEDICAL SCIENCES 
Richard P. Suttmeier, Ph.D. 



A Doctrine for Research 

From their ideology and historical experience, Chinese politi- 
cal leaders have deduced a research doctrine which guides research pol- 
icy. Although this doctrine has been remarkably consistent over the 
years, it has been sufficiently ambiguous to allow for varied interpre- 
tations in policy and implementation. At the core of China's research 
doctrine are four elements. First, Chinese research must "serve produc- 
tion" and be oriented towards the solution of practical problems gen- 
erally. Second, there has been an emphasis on indigenous capabilities; 
China's own social, intellectual and economic experiences— historical 
and contemporary— can provide the material for creating a unique (and 
ultimately, a superior) research tradition. Third, the creation of this 
tradition will involve the masses of workers and peasants and will not 
be the sole province of a professional elite. This element is justified 
on both epistemological and political grounds. Epistemologically, Marx- 
ism-Leninism as interpreted by Mao finds the origins of "correct ideas" 
in "social practice," familiarity with which is purportedly most intense 
among workers and peasants. Politically, the emergence of a modern 
technoscientific educated elite is no more acceptable to Mao than 
would be the persistence of a traditional Confucian educated elite. 
Chinese research policy therefore has been marked by periods of in- 
tense anti-professionalism. Fourth and finally, science and technology 
are to be integral and honored parts of the new China. The struggle 
for "scientific experiment", along with the struggle for production and 
the class struggle, are celebrated as the three great tasks of the revolu- 
tionary society. At the risk of oversimplifying, China's research doctrine 
might be summed up as "science for everyone, everyone a scientist." 

173 



174 MEDICINE AND PUBLIC HEALTH 

A recent study of medical sociologists, relating research environments 
with scientific innovation, reported that innovation is more likely to 
occur in marginally academic settings than in purely academic settings. 
In the former environment, the consequences of research were consid- 
ered to be more visible than in the latter, and the requirements for 
"relevance" often contributed to making research in the marginally aca- 
demic settings more difficult. 1 In part the difficulty was related to the 
fact that the problems of the "real world" defied accepted academic dis- 
ciplinary organization and procedures. If one juxtaposes these findings 
with Chinese experiences with research and development over the last 
twenty years, one finds that the Chinese, through organizational trial 
and error and much ideological exhortation, interestingly are coming 
to the same conclusions. Given Chinese research goals, which are highly 
pragmatic, the Chinese seem to be concluding that the cutting edge of 
innovation leading to the realization of those goals is where intellec- 
tual effort and social practice meet. Attempts to understand the contem- 
porary role and functions of particular research institutions such as the 
Chinese Academy of Medical Sciences (CAMS) are best made with ref- 
erence to the ideological nuances and changing organizational arrange- 
ments that have been so characteristic of research efforts in the People's 
Republic of China. 

Problems in Implementing Doctrinal Goals 

At the time of the founding of the People's Republic of 
China, the political leadership had three kinds of resources for the 
task of promoting science and technology in the new China. First, it 
had the legacy of Republican China with its established, but war-torn 
and generally underdeveloped collection of research institutions, and 
its limited number of scientists and engineers. Second, the leadership 
had its own experience in governing vast regions of China. In terms 
of population and area these regions were larger than many countries 
of the world. Although this included little or no experience in man- 
aging institutionalized research, it was an experience rich in improv- 
isation and innovation necessary to meet the exigencies of wartime 
and guerrilla existence and was a highly formative period for Chinese 
Communist leadership techniques and administrative style. Finally, the 
Chinese leaders had the advice and assistance of the Soviet Union at 
their disposal, and not surprisingly, from the Chinese perspective of 
1950, the latter was the source of greatest inspiration. While Soviet 
experience was an inspiration, the raw materials for a new research 
program had to come from the existing institutions and manpower. 
Thus initially, in the period 1949-1957, these latter resources were 
reorganized along the lines of the Soviet research system, and the sci- 



ACADEMY OF MEDICAL SCIENCES 175 

entists underwent ideological remolding to reorient them towards the 
nature of research in a socialist state. 

The two crucial aspects of the Soviet research system of the 1950's 
that impressed the Chinese were the centrality of a national academy of 
sciences and a national system of research planning. While Chinese sci- 
entists were asked to reorient themselves to Soviet science through 
learning Russian and engaging in scientific dialogue, administratively 
the Academia Sinica was being reorganized into a new Chinese Acad- 
emy of Sciences (CAS) complete with a Soviet-style secretariat (estab- 
lished in 1954) and a system of departments (hsueh-pu, otdelenie) (es- 
tablished in 1956). This system included a department of mathematics, 
physics, and chemistry, a department of biological sciences, one of earth 
sciences, one of technical sciences, and finally a department of social sci- 
ences. The departments were led by department committees (and their 
standing committees) composed of "board members" chosen from 
China's more distinguished scientists. Subordinate to the departments 
were institutes and laboratories in specialized fields. At the level of the 
institute and laboratory, the business of the Academy was run by a 
director, one or more deputy directors (often the chief Party cadres) 
and by two committees. The academic committee was responsible for 
the direction, planning and supervision of the actual research work, 
while a committee on institute affairs had responsibility for personnel, 
finances and other administrative tasks. Penetrating the levels of the in- 
stitute and laboratory as well, of course, was the ubiquitous Party or- 
ganization. 

The role of board member, which has been compared to that of the 
Soviet academician, but which was of more than honorific importance, 
was crucial to the workings of the Academy. Some board members were 
recruited from research institutions other than the Academy itself and 
held their positions at CAS concurrently with positions at universities 
and colleges and other research establishments not directly under CAS. 
The department committees were to be forums at which scientists from 
different research sectors (academy, higher education, government min- 
istry) but roughly the same fields would exchange views, plan for, and 
help coordinate the nation's research. The first major task for the de- 
partments was the formulation of a long term, 12 year plan for scientific 
research, drawn up during 1956-57 with Soviet assistance. A national 
research plan of this sort is essentially a political document since it allo- 
cates the right and the necessary resources to do certain kinds of re- 
search to some organizations and it denies those rights and resources to 
others. Disagreement arose over how much basic research should be 
done outside the CAS (and over how much basic research should be 
done), and how much applied research should be done within CAS. 



176 MEDICINE AND PUBLIC HEALTH 

The departments, along with a powerful secretariat, were to make the 
Academy the preeminent academic institution in the nation, not only in 
terms of substantive research, but as a leader in science policy as well. 
Inherent in the emerging new role of CAS was an enhancement of its 
own prestige and power at the expense of the higher education sector 
particularly, but of the government ministry sector as well. 

By 1956-57 it was apparent to scientists and administrators that this 
essentially Soviet model was not suited to China's conditions and press- 
ing needs. Instead of fostering inter-sectoral cooperation, the system 
seemed to frustrate it. Instead of promoting interdisciplinary outputs of 
information useful for "production," the system seemed to encourage 
narrowly conceived, overspecialized research constrained by the bound- 
aries of traditional academic disciplines and reinforced by the Acad- 
emy's organization into specialized research institutes. In order to com- 
pensate for the weak leadership by the CAS mechanism, the Chinese 
created a high level Scientific Planning Commission (SPC) in 1956 
which later evolved into the powerful State Scientific and Technologi- 
cal Commission (SSTC) in 1958. Although the details of the 12 year 
plan have never been made public, it is known that the plan was di- 
vided into 12 broad areas of research. The problem undertaken by the 
SPC, for which it was given the necessary authority, was to work out 
the details for administering the plan, with particular emphasis on in- 
tersectoral coordination and the avoidance of duplication of effort. Its 
strategy was to redefine the plan into 26 task areas, and to begin to en- 
force coordination among performers. Over time these coordinated per- 
forming units evolved into what might be called "micro research 
systems," and typically would include one or more institutes of CAS, 
university departments, research units under an industrial ministry, and 
units from one of the specialized academies. 

Although the opportunity for using the CAS departments as mecha- 
nisms for annual planning was not abandoned, additional mechanisms— 
particularly national conferences on especially important research 
problems, and by the early 1960's, professional societies— were used for 
this purpose. Thus by the end of the 1950's China's national research 
system had undergone two significant readjustments. First, the pre-49 
system had been remolded along Soviet lines, and second, significant de- 
partures from the Soviet model were accomplished shortly after the ini- 
tial reorganization was completed. 

Medical Research — Organization and Policy 

Medical research was not immune from these stresses and 
strains. The leaders of the People's Republic of China (PRC) inherited 
from the Nationalists a not insignificant medical establishment. Per- 



ACADEMY OF MEDICAL SCIENCES 177 

haps the two most significant institutions from the pre-49 period were 
the Peking Union Medical College complex and the national Central 
Institute of Medical Research with its 15 departments organized under 
the old Ministry of Health. The former institution produced many of 
contemporary China's leading men of medicine and continues to be an 
important medical center today, under a new name. 

Medical science no less than the other sciences was subject to the im- 
plications stemming from the interactions of ideology, doctrine and or- 
ganization. Medical research, too, was to be oriented towards practice 
and China's more pressing problems. Medical research was included as 
one of the "12 points" of the 12 year science plan and was to concen- 
trate on "prevention and eradication of a number of diseases most det- 
rimental to the people's health." This concern for "common and recur- 
ring" diseases has been official policy for 20 years but has received 
added emphasis in the post-Cultural Revolution period. The doctrinal 
stress on indigenous capabilities which applied to all sciences was con- 
siderably more meaningful in medicine than in other areas. From the 
very early days of the PRC, stress was placed on indigenous Chinese 
medicine, and personnel trained in Western medicine were urged to 
study Chinese medicine. Additional emphasis has been placed on 
Chinese medicine since late 1958 when Mao Tse-tung made his now fa- 
mous statement that "Chinese medicine and pharmacology are a great 
treasure house. Efforts should be made to explore them and raise them 
to a higher level." 

The attention to Chinese medicine is not unrelated to the third doc- 
trinal point urging integration with the masses. In part, traditional 
Chinese medicine has been interpreted as an expression of the wisdom 
of the masses and hence a bona fide source of new knowledge. Anti-elit- 
ism has been expressed in programmatic forms as well, presented most 
graphically perhaps in a series of photos reproduced in the December 
1965 issue of the Chinese Medical Journal showing the president of the 
CAMS and other leading medical scientists practicing in the country- 
side as members of mobile medical teams and learning about the health 
problems of the common man. 2 This "downward" transfer of medical 
intellectuals has received considerable emphasis during and after the 
Cultural Revolution, in part to compensate for the urban-rural split 
that allegedly had developed as a result of the mistaken, urban oriented 
policies of the Ministry of Health during the early 1960's. 

Research on Traditional Chinese Medicine 

Because of the centrality of a national academy of sciences 
in the Soviet model, Chinese organizational efforts in the early 1950's 
were directed towards the CAS, with relatively little attention to med- 



178 MEDICINE AND PUBLIC HEALTH 

ical research. The first new organizational departure in medical re- 
search, in keeping with the emphasis on indigenous capabilities, was 
the establishment of the Academy of Traditional Chinese Medicine in 
Peking in December, 1955. In noting the opening of the Academy, a 
People's Daily editorial stressed the importance of making the Acad- 
emy's work directly relevant to the treatment of widespread diseases. 
Its initial research program reflected this policy, emphasizing work on 
diseases of the liver and gall bladder, asthma, rheumatism, intestinal 
diseases, dropsy, high blood pressure, cancer, and tuberculosis of the 
bone and lymph glands. The new Academy had research institutes in 
four fields: medicine, surgery, acupuncture and pharmaceutics. 3 The 
original staffing consisted of thirty doctors trained in Chinese medicine 
who had available to them modern laboratory facilities. The feature 
of the new Academy which made it most unique was the inclusion of 
120 doctors trained in Western medicine who were to undergo simul- 
taneously training in Chinese medicine and participate in research on 
(the scientific basis of) traditional medicine. During the course of the 
next decade, the Academy had expanded its research to include the 
herbal treatment of leprosy, heart disease, disease of the nervous sys- 
tem, blood, eyes, bone fractures and gynecology. A fifth institute for 
rural diseases was added as were two hospitals. The research staff had 
expanded to 300 and some 200 doctors of Western medicine had re- 
ceived training at the Academy, as had 100 doctors from other coun- 
tries. 4 

As with most other areas of research in China, the organization of 
research on Chinese medicine is decentralized. Under the general direc- 
tion of the Academy of Traditional Medicine, provincial research insti- 
tutes were established. One significant example of such an institute is 
the Szechwan Institute of Traditional Medicinal Materials, located in 
the area of west China which produces one third of China's herbal med- 
icine. Again, similar to other research organizations, the Academy is 
tied in to a micro-system which is directed by a special unit for research 
on Chinese medicine in the State Scientific and Technological Commis- 
sion whicli works closely with the Ministry of Health and includes hos- 
pitals and clinics, training and educational institutions, regional re- 
search institutes, appropriate professional societies under the Chinese 
Medical Association and institutes of the Chinese Academy of Medical 
Sciences. 

Modern Medical Science 

In moving from research on Chinese medicine to Western 
medical science one is again struck by the early influence of the Soviet 
model and the subsequent departure from that model. Soviet influence 



ACADEMY OF MEDICAL SCIENCES 179 

in medicine began in the early 1950's as it did in the sciences generally. 
Chinese medical researchers were well represented in an important 
CAS delegation that went to Moscow in 1953 to lay the groundwork for 
Sino-Soviet scientific and technological cooperation. Ties with the 
Soviet Union in the field of medical science continued throughout the 
1950's and may have reached their fullest expression in the only known 
agreement between the Soviet Academy of Medical Sciences and 
CAMS, signed in I960. 5 Ironically, this came at a time when govern- 
ment to government relations were beginning to deteriorate. 

The establishment of the Chinese Academy of Medical Sciences 
under the Ministry of Health in 1956 appears to be an emulation of the 
Soviet model. As in the Soviet Union, CAMS was administratively an 
organ of a central ministry, but had extensive functional ties with the 
national academy of sciences and with other sectors of the nation's re- 
search system. 6 These ties in China were institutionalized initially 
through the pervasive system of "concurrent positions," alluded to 
above. As noted by Cheng Chu-yuan in his biographical survey of 1200 
Chinese scientists, most scientists wore at least three hats: they were 
professors in an institution of higher education, research fellows in one 
of the academies, and members of an academic Committee for a re- 
search institute. 7 CAMS was represented at CAS by placing eight of its 
people as board members of the Department of Biology, (as of 1964). 
Some 14 other Department of Biology board members had their main 
areas of interest or responsibility in the medical and public health 
field. Since there were 65 board members in biology, this meant that 
approximately one third were from medicine. 

Knowledge of budget procedures for Chinese research and develop- 
ment is very limited. Western analysts assume that most civilian R&D 
is financed out of a central science budget, which supports the work of 
the academies as well as the research performed by educational institu- 
tions and government ministries. 8 It was estimated that prior to the 
Cultural Revolution, CAS spent about 30 per cent of the science 
budget, while only 5—10 per cent went to CAMS and the Academy of 
Agricultural Sciences combined. 9 Since the work of CAMS is super- 
vised by both the Ministry of Health and Science and Technology 
Commission, it is possible that funds from the science budget flow to 
CAMS through both of those organizations. In addition, however, 
CAMS has undertaken some non-research health work, such as the par- 
ticipation of the Institute of Dermatology and Venereology in anti-ve- 
nereal disease campaigns, and may receive funds for such work from the 
program budget of the Ministry of Health. The emphasis on the decen- 
tralization of research in recent years further complicates budgeting 
procedures since one of the reasons prompting the Chinese to decentral- 



180 MEDICINE AND PUBLIC HEALTH 

ize government activities has been to relieve the central government of 
financial burdens. It is possible, therefore, that since the Cultural Revo- 
lution, a larger share of the costs of medical research is being financed 
by local government. 

Precise figures for the number of people employed at CAMS and its 
affiliated institutions are, like budget data, difficult to come by. The 
last reasonably reliable figures are from 1958, at which time it was esti- 
mated that some 4,327 people were employed at CAMS. Of these, 629 
were considered "scientific workers," (the rest were auxiliary staff) only 
102 of whom were considered "senior scientists". 10 A safe assumption is 
that the number of scientific workers increased four times by the begin- 
ning of the Cultural Revolution in 1966. 11 

The organization of CAMS is somewhat less complicated than CAS. 
At the top of the organization chart is a president and four vice presi- 
dents. Huang Chia-ssu, now 65 years old, has occupied the President's 
position since 1959. Huang, a chest surgeon, received his M.D. from Pe- 
king Union Medical College in 1933, and received an M.S. from the 
University of Michigan in 1943. He is a member of the Communist 
Party and prior to the cultural revolution held four other posts which 
related to his work at CAMS. First, he was President of the China Med- 
ical College. He represented CAMS and the medical community as a 
board member and member of the standing committee of the Depart- 
ment of Biology of CAS. He was also a vice-chairman of the China As- 
sociation for Science and Technology (CAST), an organization that 
oversees Chinese professional societies and also has responsibility for 
popularizing science and technology. Finally, Huang was a vice-chair- 
man of the Chinese Medical Association (CMA), the "peak organization" 
for more specialized medical societies, which is subordinate to CAST. 

Prior to the cultural revolution, the vice-presidents included Hsueh 
Kung-ch'o, Shen Chi-chen and Lin Chiao-chih. Hsueh is a physiologist 
but his educational background is uncertain. In the course of his career 
since 1949 he has also been a vice-president and secretary of the CCP 
committee of the Chinese Medical University, secretary-general of the 
Chinese Medical Association and vice-chairman of the China Physiol- 
ogy Society. Shen's educational background is also unknown, but he did 
hold a position as board member, and member of the standing commit- 
tee of the Department of Biology, CAS. Since there are a large number 
of women researchers employed at CAMS, it is fitting that a distin- 
guished woman medical scientist be included as a vice-president. Lin 
Ch'iao-chih, like many other senior medical personnel, is a product of 
Peking Union Medical College. She is a board member of the Depart- 
ment of Biology, CAS, and is director of the Department of Obstetrics 
and Gynecology of CAMS. She also holds posts in CAST, the Chinese 



ACADEMY OF MEDICAL SCIENCES 181 

Medical Association, and heads the department of obstetrics and gyne- 
cology of a Peking medical school. In addition, Lin held a very signifi- 
cant position as head of the CMA's Committee on Directing Birth Con- 
trol Technology which works with the Ministry of Health and local 
government and party organs, in directing and implementing China's 
population control policies. 

Also mentioned as vice presidents of CAMS have been Pai Hsi-ch'ing, 
Chang Chih-ch'iang and Huang Hu. Very little is known of Pai, al- 
though he was listed as a vice-president as late as 1965. 12 Chang is exclu- 
sively a Party man with no known professional background in medi- 
cine. In 1958 he was the first secretary of the CCP Committee of CAMS 
and by 1960 he was listed as a vice-president. In 1966, he may have re- 
linquished his post at CAMS in becoming the Director of the Political 
Department of the Ministry of Public Health. Little is known of the 
career of Huang Hu. 

Like the Academy of Sciences, a system of departments forms the sec- 
ond layer of organization of CAMS. These include the following: bacte- 
riology and immunology, biochemistry, chemistry, hygiene, internal 
medicine, microbiology, nutrition, obstetrics and gynecology, pathol- 
ogy, experimental morphology, pharmaceutical chemistry, therapeutics, 
pharmacological botany, pharmacology and experimental therapeutics, 
physiology, sanitation, surgery, and virology. Little is known of the op- 
eration of these departments but presumably they were intended to 
help provide "academic leadership" and to aid in planning. One would 
expect to find therefore large numbers of the department members hold- 
ing concurrent positions at medical schools and hospitals. 

The system of concurrent positions can better be understood by hy- 
pothesizing membership patterns for a single department, let us say sur- 
gery. One hypothetical member, Dr. Lin, will be employed chiefly at the 
CAMS itself at the Institute of Tuberculosis Research in Peking. An- 
other member, Dr. Huang, will find his chief place of employment at a 
major hospital in Shanghai where he will be a leading member of that 
hospital's surgical department. A third hypothetical member, Dr. 
Chang, will spend most of his time as a professor of surgery at a leading 
medical school. All three would be surgeons engaged in research, but 
with different principal places of employment, and in the cases of the 
last two members, those places of employment would not necessarily be 
under the administrative responsibility of CAMS. In terms of planning, 
insuring that ideas filter up to policy makers, coordination, and imple- 
mentation of research policy, the three members have much in common 
and the use of the department mechanism of concurrent positions was 
designed to facilitate the performance of those functions. In actuality, 
our three hypothetical individuals would probably have professional re- 



182 MEDICINE AND PUBLIC HEALTH 

sponsibilities in more than one institutional setting. Dr. Lin, for exam- 
ple, might teach at a local medical school and also may be attached to a 
surgical staff of a CAMS affiliated hospital. Similar multiple responsi- 
bilities may be imagined for Drs. Huang and Chang. If one excludes 
the responsibilities within the academy sector, the professional roles of 
research-oriented surgeons in China would seem quite similar to those 
in the United States. 

Below the departments are the actual research performing units 
themselves, the 17+ institutes of CAMS, and its five affiliated hospitals. 
Most of the institutes were created after the establishment of CAMS, 
although a few antedate it. For the most part they are led by directors 
who have had advanced training outside of China. The striking feature 
about the institutes is the close association they maintain with hos- 
pitals, medical schools and relevant institutes of CAS. In this connection 
it is important to remember that there is a great deal of medical 
research in China done in institutions not related to CAMS through 
direct administrative ties. The Ministry of Health operates some 
institutes such as the Institute of Vaccine and Serum Research indepen- 
dently of CAMS. Others are run by local governments, such as the 
Kiangsu Provincial Anti-Schistosomiasis Research Institute, and some 
100+ hospitals around the country are engaged in research. 

In addition, institutes under CAS's Department of Biology are en- 
gaged in medical research. Physiologist Chang Hsiang-t'ung (Ph.D., 
Yale, 1946) for instance has been working on the theoretical aspects of 
acupuncture at the Institute of Physiology (Shanghai) since 1965. 13 
The Institute of Pharmaceutical Research (Shanghai) has been active 
in producing new drugs. The Institute of Materia Medica and other in- 
stitutes have also been active in medically related research. There are 
also provincial academies of medical science. Since 1958-59 there have 
been continuing attempts to decentralize research in China. The estab- 
lishment of provincial academies are one institutional manifestation of 
decentralization efforts. These provincial academies maintain close ties 
with the central Academy, but are administratively subordinate to 
provincial governments. 

The key concept in Chinese research administration seems to be sys- 
tematic cooperation, built around micro research systems. Regardless of 
institutional affiliation, research units with common interests and mis- 
sions are expected to work together closely. In reporting the production 
of a new antibiotic "Qingdamycin," for instance, the New China News 
Agency noted that the innovation was the result of joint efforts by 36 
units, of which three were identified: the Microbiology Laboratory of 
the East China Institute of Sub-Tropical Plants, under CAS, the Shang- 
hai #4 Pharmaceutical Plant, and the Szechuan Medical College. What 



ACADEMY OF MEDICAL SCIENCES 183 

this and many other cases like it suggest is that Chinese research has 
evolved to the point where much of it is carried on by temporary forms 
of organization which bring together talents and resources residing in 
permanent institutions for the sake of solving particular problems. As 
such the system bears a rough resemblance to the idea of project man- 
agement in the United States, and is characterized by organizational 
impermanence, task orientation, regular exposure to practical problems 
and the blurring of distinctions between pure and applied research. 
The research units with which CAMS has maintained linkages are 
noted in the detailed descriptions of the institutes found in the appen- 
dix. 

In 1958, CAMS undertook a significant new responsibility with the 
opening of the China Medical College. Like its counterpart institution 
in the natural sciences, the University of Science and Technology which 
opened the same year under the CAS, the Medical College was to be 
training ground for China's future medical elite. It was to be directly 
supervised by CAMS, and employ CAMS personnel on its faculty in 
turning out highly educated medical scientists. The stress on profes- 
sional quality and the length of training (eight years) brought the idea 
of the Medical College under severe criticism during the Cultural Revo- 
lution. It was held up as one more example of the serious mistakes 
which characterized the policies of the Ministry of Health. 

Research in the Post Cultural Revolution Period 

The complete story of the impact of the Cultural Revolution 
upon China's science and technology remains to be told, but enough 
is known to piece together a rough picture of what occurred and what 
resulted. In the original "16 point program," which served as the blue- 
print for the Cultural Revolution, there was explicit reference to sci- 
entific research and the importance of sparing scientists from unneces- 
sary disruption. As the Cultural Revolution proceeded, however, the 
research establishment became involved and there is no doubt that re- 
search work was disrupted. Significantly, however, the individuals in 
the research establishment most subject to political attack were the 
non-scientist administrators of research, particularly personnel at the 
SSTC, the Secretariat and Party organization in CAS, and some scien- 
tists who were politically visible by virtue of their holding significant 
administrative posts. There is no evidence of a widespread purge of 
scientists, although the organizational environment for research, whicli 
had stabilized in the early 1960's after the reorganizations of the 1950's, 
was again disturbed. A further move towards decentralization seems 
to have occurred with some technology-oriented institutes of CAS re- 
moved and placed under local government authority. The past system 



184 MEDICINE AND PUBLIC HEALTH 

of governance at the academies has been replaced by the institution of 
the revolutionary committee. At the level of individual institutes, the 
old two committee system (committee for institute affairs, academic 
committee) has now been abolished and has been replaced by one 
"three in one" combination committee, composed of workers, leader- 
ship cadres and research personnel. In spite of these fundamental or- 
ganizational changes, reports from Western visitors indicate that re- 
search continues. 14 

In the area of medical research, the picture is complicated by the fact 
that medical and health policies and the Ministry of Health itself came 
under very heavy attack during the Cultural Revolution. The Ministry 
of Health was accused of neglecting medical care in rural areas and the 
treatment of "common disease" in favor of high proficiency in training 
and specialization, and of giving attention to problems of interest only 
to professional scientists. One manifestation of this "mistaken" policy 
was the eight-year medical education program at the China Medical 
College. This program was taken as the epitome of the overemphasis on 
professionalism, specialization and detachment from the real medical 
problems of a rapidly changing China. Once the attack on the program 
was begun, it gave rise to the following ditty composed by revolution- 
ary students: 

"These eight years in the old China Medical College— 
The havoc they wrought! 
In three years, no medicine did we glean; 
In five years, no patients were seen; 
A full eight years, and no contact with workers and peasants brought." 1S 

Medical research similarly came under attack for being under the in- 
fluence of "bourgeois authorities" and experts who allegedly "pursued 
personal fame and gain . . . [who] used to shut themselves up in their 
laboratories to study rare diseases which involved complicated treat- 
ment." 16 To combat this syndrome, additional emphasis was placed on 
sending medical researchers to the countryside, as mobile medical 
teams, and there were reports that some medical workers, including 
some from CAMS were to be resettled more permanently in the coun- 
tryside. 17 These post-Cultural Revolution measures, when expressed nu- 
merically, represent perhaps the greatest redeployment of professional 
manpower the world has ever seen. According to one report, some 
330,000 medical workers (doctors, nurses and support personnel) from 
urban areas have "settled permanently" in the coutnryside. Another 
400,000 doctors and nurses have been recruited into mobile medical 
teams. 18 Recent Western visitors report that they were informed that 
"one third of the faculty of China's medical schools and hospital staff 
must be in the countryside at all times . . ." 19 



ACADEMY OF MEDICAL SCIENCES 

The emphasis in medical research, then, in the post-Cultural Re 
tion period is increasingly on a fuller implementation of Mao's pi 
pies of attention to rural health needs, and combining Western 
Chinese medicine in practice and in research. Much of the latter 
appears to be going on at the province level at provincial institul 
and indeed the transfer of professional medical personnel from the 
demic centers (particularly Peking and Shanghai) may have the 
ondary effect of strengthening these provincial units. 

In spite of all this, CAMS appears to have survived the Cultura 
volution and research continues. President Huang Chia-ssu has alsc 
vived and continues to have an active leadership role at CAMS, p 
bly as a leading member of the Academy's Revolutionary Comm 
Vice-president Lin Chiao-chih also continues to be active both ii 
position at CAMS and as head of the Department of Gynecology 
Obstetrics of Peking Fanti (Anti-imperialist) Hospital (recentl 
named). 20 Recently Ch'en Wen-chieh, director of the Blood Transfi 
and Hematology Research Institute of CAMS was one of two Ch 
delegates to the McGill University Sesqui-Centennial Conference, ; 
suggesting a certain continuity of medical research personnel in 
and post-Cultural Revolution China. 21 In a recent report on his tr 
China, Dr. E. Grey Dimond noted active research at the Institut 
Industrial Hygiene, Cancer Research, Experimental Medicine, E 
miology, Virology, Antibiotics, Hematology, Parasitology, Medica 
ology and Dermatology. 22 

Increasingly, reports of medical breakthroughs come less from i 
emy institutes than from medical schools and their associated hosr. 
The most celebrated of all new developments in Chinese medicine, 
puncture anaesthesia, poses an interesting case of the relationshi 
tween academic research and practical innovation which characti 
the post-Cultural Revolution research system. As suggested above, 
ous medical research on acupuncture, using modern methods, 
begun in the mid-1950's, and presumably continued. It is not 
whether at any time this research was oriented specifically to\ 
using acupuncture for anaesthetic purposes. Rather the official ve 
of the origins of acupuncture anaesthetic stresses that it was begu 
ideologically inspired health workers during the Great Leap For 
who first used it to stop pain from toothache, tooth and tonsil « 
tions, and sore throats. Achieving success with these measures, 
then tried using the new techniques on other minor operations wil 
using chemical anaesthetics. They were again successful. The dev 
ment of acupuncture anaesthetic did not progress beyond this r. 
however, because the Ministry of Health, under the influence ol 
Shao-ch'i, discouraged serious attention to it. It was only aftei 



186 MEDICINE AND PUBLIC HEALTH 

changes wrought by the Cultural Revolution that a "mass movement" 
was begun for the clinical use of acupuncture anaesthesia and for scien- 
tific studies of it. 

This case is instructive, and is typical of many official reports of inno- 
vations in China. These tell us that many innovations originate outside 
formal research settings, "in practice," and sometimes run counter to 
accepted professional wisdom. They tell us too that formal research or- 
ganizations in China have as a key part of their activities the "sum- 
ming up," interpretation and explanation of these new innovations. Fi- 
nally, they tell that when the innovation is truly anomalous, as in the 
case of acupuncture anaesthesia, the academic research units are ex- 
pected to take up these anomolies as new topics for basic research. 23 If 
the cutting edge of new innovation comes outside of purely academic 
settings, as predicted by ideology, the importance of institutions such as 
CAMS as originally structured, will be diminished in the eyes of na- 
tional policy makers. 

Although medical research will continue to reflect the research pol- 
icy's emphasis on practical matters, it should be remembered that that 
same policy has consistently made allowances for basic research, and 
has stressed the importance of reaching and surpassing "world levels." 
Research administrators around the world who are plagued with recon- 
ciling the organizational requirements of applied research and develop- 
ment with those of basic research should find China's evolving policies 
in this area worthy of their attention. The trend, at this writing, ap- 
pears to be towards encouraging both at the interfaces of academic in- 
stitutes, hospitals, clinics, mobile medical teams, and medical schools. 



ACADEMY OF MEDICAL SCIENCES 187 

REFERENCES 

1. Gordon, G., and Marquis, S.: Freedom, "Visibility of Consequences, and Scientific 
Innovation". American Journal of Sociology 72: 195-203, September, 1966. 

2. Mobile medical teams were composed of fully trained medical personnel and 
should be distinguished from the teams of paramedical "barefoot doctors" which 
appeared during the course of the Cultural Revolution. 

3. Research Academy of Chinese Medicine Opens. New China News Agency (here- 
after NCNA) release, Peking, December 12, 1955, as reported in U.S. Consulate 
General, Hong Kong: Survey of China Mainland Press (hereafter SCMP), 1194. 

4. Chinese Medical Research Academy Marks 10th Anniversary. NCNA release. 
Peking, January 29, 1966, as reported in SCMP 3629. 

5. Johnston, D. M., and Chiu, H.: Agreements of the People's Republic of China 
1949-1967: A Calendar. Harvard University Press, Cambridge, Mass., 1968, p. 108. 

6. See, Friedman, S. M.: "Basic Research in the Soviet Union." BioScience 19: 
549-552, June, 1969. 

7. Cheng, C. Y.: Scientific and Engineering Manpower in Communist China, 1949- 
1963. National Science Foundation, Washington, D.C., 1965. 

8. Orleans, L.: Professional Manpower and Education in Communist China. Na- 
tional Science Foundation, Washington, D.C., 1961. p. 15. 

9. Wu, Y. L., and Sheeks, R. B.: The Organization and Support of Scientific Re- 
search and Development in Mainland China. Praeger Publishers, New York, p. 
200. 

10. Cheng, p. 27. 

11. A fourfold increase in the number of research workers since 1956 in CAMS 
and the Academy of Traditional Chinese Medicine taken together was reported 
in a New China News Agency dispatch from Peking on March 16, 1963 (SCMP 
2942). 

My estimate is based on viewing the 1958 figure as a fraction of total scientific 
research manpower from the same year and extrapolating a figure for 1966 on 
the basis of total manpower increases, keeping the fraction of medical research- 
ers constant. 

12. Chinese Medical Journal 84: April 1965. 

13. Fukien Radio, as reported in Foreign Broadcast Information Service: August 5. 
1971. 

14. See for instance, Dimond, E. G.: "Medical Education and Care in the People's 
Republic of China." JAMA 218: 1552-1557, December 6, 1971. 

15. "Thoroughly Criticize and Repudiate the Eight Year Medical Education Program 
Pushed by China's Khrushchev." China Medicine 3:164-169, March 1968. 

16. New China News Agency, December 2, 1965, as reported in Foreign Broadcast 
Information Service: December 4, 1969. 

17 Kuang Ming Daily, June 24, 1970, as reported in Foreign Broadcast Information 
Service: July 13, 1970. 

18. China Science Notes. Ill: p. 6., January 1972 (Compiled and distributed under 
the auspices of the Committee on Scholarly Communication with the People's 
Republic of China. National Academy of Sciences.) 

19. China Science Notes. 

20. Peking Radio, as reported in Foreign Broadcast Information Service: November 
9, 1971. 

21. China Science Notes: p. 15. 

22. Dimond, 1555. 



|88 MEDICINE AND PUBLIC HEALTH 

23. See the discussion of acupuncture anaesthesia in China Reconstructs XX: 2-5, 
October, 1971. 



ACADEMY OF MEDICAL SCIENCES 189 

APPENDIX 

Institutes and Hospitals under 
the Chinese Academy of Medical Sciences 



Information concerning the following institutes was compiled from 
Cheng, C.Y.: Scientific and Engineering Manpower in Communist 
China, 1949-1963; National Science Foundation, Washington, D.C., 
1965; Surveys and Research Corporation: Directory of Selected Scien- 
tific Institutions in Mainland China; Hoover Institution Press, 1970; 
and from scattered primary sources. Cheng (p. 27) notes that in 1963, 
CAMS had 20 institutes under its supervision. The Directory of Se- 
lected Scientific Institutions in Mainland China provides information 
on only 14 institutes. CAMS President Huang Chia-ssu, in a 1966 inter- 
view reported by the New China News Agency, claimed that the Acad- 
emy had 17 institutes. 

A. Institute of Acupuncture and Moxibustion: Peking 

B. Institute of Antibiotics: Peking 

C. Institute of Biologicals: Peking 

D. Institute of Blood Transfusion and Hematology: Peking 

E. Institute of Cardiovascular Diseases: Peking 

F. Institute of Dermatology and Venereology: Peking 

G. Institute of Epidemiology and Microbiology: Peking 
H. Institute of Experimental Medicine: Peking 

I. Institute of Hypertension: Shanghai 

J. Institute of Internal Medicine: Peking 

K. Institute of Labor Hygiene, Labor Protection and Occupational 

Disease Research: Peking 

L. Institute of Medical Biology: Peking 

M. Institute of Medical Radiology: Canton 

N. Institute of Neurosurgery: Peking 

O. Institute of Occupational Health, Environmental Health and 

Nutrition: Peking 

P. Institute of Oncology: Peking 

Q. Institute of Ophthalmology: Peking 

R. Institute of Parasitology: Nanking 

S. Institute of Pediatrics: Peking 

T. Institute of Pharmacology: Peking 

U. Institute of Surgery: Peking 

V. Institute of Traditional Chinese Medicine: Peking 



190 MEDICINE AND PUBLIC HEALTH 

W. institute of Tuberculosis Research: Peking 
X. Institute of Virology: Peking 

II. 

Associated Hospitals 

Fanti Hospital, Peking 

Fu Wai Hospital, Peking (head and chest surgery) 

Peking Union Hospital 

Peking Tumor Hospital 

Hsiian Wu Hospital, Peking (neurosurgery) 



III. HEALTH PROBLEMS 



POPULATION DYNAMICS 
Leo A. Orleans 



It is much more satisfactory to be born and to die with the 
assistance or in the presence of a representative of the medical pro- 
fession. It is at this most basic level that population relates to medicine 
and public health. The improved health conditions that follow an in- 
crease in medical manpower and facilities together with other factors 
in the development process inevitably result in the survival of more 
babies (reduction of infant mortality) and a longer life (increase in life 
expectancy). Unfortunately, a developing country that achieves the 
desired drop in mortality— usually a matter of top priority— must also 
be prepared to cope with a not so desirable increase in the rate of 
population growth and the inevitable economic problems that ensue 
from the created imbalance between production and consumption. 
Medical sciences share in responsibility for this dilemna by reducing 
the death rate; and medical sciences are also asked to solve it by re- 
ducing the birth rate. 

The People's Republic of China is an ideal country in which to view 
the interrelationship between the medical-public health revolution and 
population, for despite the lack of hard data for systematic analysis, the 
process described above was easily discernible and much of it was played 
out in a short period of just twenty years. It is therefore most appropriate 
for any person interested in China's achievements and problems in 
public health and medicine also to have some understanding of the 
nation's population dynamics. 

THE POPULATION RECORD 

An excursion into China's historical population record is a 
fascinating experience. Unfortunately, however, although the available 

193 



194 MEDICINE AND PUBLIC HEALTH 

figures go back thousands of years, they tell us much more about 
Chinese society and culture than about the population record itself. 
The various series have gaps that range from a few years to a few 
centuries and can not be used without some rather subjective analysis 
and adjustments; the resulting estimates remain very tentative indeed. 

In the first half of the 20th century several efforts were made to 
enumerate the population of China by the tottering Manchu Govern- 
ment, by the new Republican Government and by a member of the 
institutions and ministries of the Kuomintang. The results continued to 
be only approximations and the figure of 450 million that was cited by 
the League of Nations in the 1930's survived for the purpose of general 
usage for almost two decades. 

The 1953 Census 

The inaccuracies of the old population figures were recog- 
nized by the Chinese Communists, as was the need for something bet- 
ter, not only to provide population data for national planning pur- 
poses but also to register voters for the upcoming elections. The prob- 
lems involved in such a massive effort to cover hundreds of millions 
of people scattered over tens of thousands of square miles was also 
appreciated. Obviously the solution was a population count and prep- 
aratory work started at the end of 1952. Because of the difficulties in- 
volved in any attempt to count hundreds of millions of people scat- 
tered over 3.7 million square miles of land area, Peking was forced to 
make two basic decisions. First, it was not going to be a census with 
canvassers visiting every household, but rather a registration in which 
the head of the household would come to the registration office and 
report all those living under his roof. Second, the count was going to 
be as simple as possible, and would contain only four items of informa- 
tion: name, date of birth, sex, and nationality. Even this, however, 
turned out to be an extremely difficult procedure that took more than 
a full year to complete. The product of this effort is known as the 1953 
Census of the People's Republic of China and the final tabulations 
were reported by the State Statistical Bureau on November 1, 1954. 

According to this report, at midnight on June 30, 1953 the total pop 
ulation on the Chinese mainland was 582,603,417 (sic!), plus 
11,743,320 overseas Chinese and 7,591,298 persons on Taiwan, for a very 
precise grand total of 601,938,035. Of this total 51.82 percent were men 
and 48.18 percent were women. Also included in the initial report were 
information on the provincial distribution of the total population, 
some scanty age data, urban-rural distribution of the total population, 
including the inhabitants in cities of over 500,000, and the distribution 
of the countrv's national minorities. 



POPULATION DYNAMICS 195 

The crucial question, of course, is how valid are the reported results? 
Was China, in fact, able to take its "first modern census" as claimed by 
the regime? 

Considering the fact that it takes almost the full ten years to plan 
and execute a decennial census in a western country and that even then 
results are subject to considerable error, it is easy to find reasons for cast- 
ing doubt on the validity of the 1953 effort. The Chinese instinctive 
reluctance to being registered (or counted), the extension of the census- 
taking period to almost a year, the manual tabulation of millions of 
registration forms by poorly motivated and poorly trained "counters" 
and many other factors would cause our Western statisticians certain 
apoplexy. There are adequate factors, however, which to some extent 
balance the criticisms and make acceptance of the 1953 census not sim- 
ply a matter of wishful thinking. 

The census was a sincere effort to obtain accurate population data. 
By 1953 the regime had secured complete control over the land, with 
both the Party and the government structure and power reaching down 
to the lowest administrative units and industrial and agricultural or- 
ganizations. The lead time for the census was short, but the training 
effort was intensive. The simplicity of the basic schedule and the length 
of time it took to register the population and tabulate the results would 
suggest that the Chinese tried to overcome inherent difficulties and ar- 
rive at a reasonable headcount of the population on the Chinese Main- 
land. Finally, the Chinese themselves use the same data that were re- 
leased to the world. 

In sum, the 1953 effort was not a "modern census" by any stretch of 
the imagination, but it was probably the best head-count ever taken in 
China. Because there is no reasonable alternative to the total popula- 
tion reported by the 1953 census, it is difficult to determine the effect of 
expediency in tilting the balance toward acceptance rather than rejec- 
tion of this figure. At any rate, it is almost universally accepted and 
used as a basis for all projections of the size of the population of China. 

Population Registers 

The 1953 census provided Peking with a population for a 
specific date, but the only way to maintain a population record be- 
tween formal counts is through a system of population registers. The 
first efforts to maintain a register of the population were limited pri- 
marily to the urban areas and were the responsibility of the Ministry 
of Public Security. Not only was this population more concentrated 
and thus easier to survey, but the need to control migration into and 
between cities also promoted the establishment of a registration system. 
Sporadic efforts to register births, deaths, and population were also 



196 MEDICINE AND PUBLIC HEALTH 

initiated in scattered areas. In both urban and rural areas, however, 
the coverage was incomplete and only occasional figures for small areas 
were reported, presumably on the basis of these registers. 

Peking had to cope with three major difficulties before it could effect 
any substantial improvement in the registration system: (1) a shortage 
of trained personnel; (2) administrative deficiencies; and (3) tradi- 
tional habits of thought which tended to militate against a conscien- 
tious regard for accuracy on the part of individuals directly or indi- 
rectly responsible for the collection and processing of statistical data. 
Furthermore, the generally inept rural personnel who were responsible 
for filling out innumerable statistical forms usually considered the col- 
lation of population data as the least important of their tasks. It is 
small wonder then that during the 1950's statistical journals were prone 
to complain that "falsification and blind estimates must be resolutely 
curbed." 

The difficulties the Chinese government had in devising and imple- 
menting the necessary procedures for population registers is reflected in 
the fact that as late as 1954 some provinces held conferences to draw up 
plans for a population registration system and that in 1955 a newspaper 
editorial complained that the results of the census were already out- 
dated and there was still no registration system to provide the regime 
with up-to-date population figures. In a January 1956 directive, the 
State Council attempted to overcome some of the problems by transfer- 
ring all the responsibilities for household registration from various 
civil departments to the Ministry of Public Security. Vesting the re- 
sponsibility in this Ministry rather than in the State Statistical Bureau 
or the Ministry of Internal Affairs is most indicative of the fact that the 
main reason for establishing the registration system was not to main- 
tain population records but to control the population. The first article 
of the regulations governing registration states: "These regulations are 
enacted to maintain social order, to protect the rights and interests of 
the citizen, and to serve Socialist construction." 

Despite the shaky nature of the registers, in June 1957 the State Sta- 
tistical Bureau managed to issue what stands today as the only official 
series of national population figures ever to be published by Peking: 

End of Year : Number (000's) : Percent Increase 

1949 541,670 ... 

1950 551,960 1.90 

1951 563,000 2.00 

1952 574,820 2.10 

1953 587,960 2.29 

1954 601,720 2.34 

1955 614,650 2.14 

1956 627,800 2.14 



POPULATION DYNAMICS 197 

Since the only possible source for these figures is the registration system 
which admittedly did not even exist during most of the years covered 
by the report, there is every reason to be suspicious of the data. The ex- 
planation that accompanies the figures only tends to support any doubts 
one might have about them. It must be pointed out, however, that, be- 
cause they are unique and because they are official, the figures are gen- 
erally accepted and widely used. 

Well aware of the existing problems with population registers, 
Peking adopted a new set of regulations early in 1958 which were to 
tighten up and improve the system. It is impossible to say if this new 
effort might have turned out to be an improvement over the previous 
years, because the new regulations were soon overtaken by the ill-fated 
Great Leap which raised havoc with the economy and destroyed the in- 
fant statistical system. During the "three bitter years" that followed, 
natural calamities, food shortages, the withdrawal of Russian aid, and 
the disruptive effects of the Great Leap created conditions under which 
population statistics could hardly have concerned either the local statis- 
tical worker or the official in Peking. A few years later, with the gradual 
recovery of the Chinese economy, new attempts were made to reestablish 
the statistical organization. The slow and painful efforts understand- 
ably concentrated on economic data more vital to China's recovery 
than on population statistics, and were probably once again disrupted 
by the distrubances brought on by the Cultural Revolution. 

The All-Purpose Figures 

Considering the problems China has been experiencing in 
establishing a workable system of population registers and the political 
and economic crises that periodically disrupted the country and the 
statistics, the fact that since 1957 there has not been a single demo- 
graphically-based figure published concerning the country's population 
should not surprise anyone. Peking does not have an accurate figure 
of China's total population; certainly the often-used totals, which, over 
the years have progressed from 600, to 650 to 700, and now occasion- 
ally to 750 million, are nothing more than general all-purpose figures 
that provide a reasonable order of magnitude for use in speeches, arti- 
cles and other writings. 

Although most of those who have been most intimately concerned 
with the size of China's population have long insisted that Peking does 
not know how many people live on its territory, the more casual ob- 
server of the population scene was much more prone to insist that the 
People's Republic with its controls and with the needs of a planned 
economy must know the size of its population and, for some unex- 
plained reason, is only keeping it a secret. Recently, however, a high 



198 MEDICINE AND PUBLIC HEALTH 

Chinese official admitted the absence of national population statistics. 
In November 1971 Vice Premier Li Hsien-nien made the following sur- 
prising admission to a correspondent of a Cairo newspaper: 

". . . Some people estimate the population of China at 800 million and some 
at 750 million. Unfortunately, there are no accurate statistics in this con- 
nection. Nevertheless, the officials at the supply and grain department are 
saying confidently, 'The number is 800 million people.' Officials outside 
the grain department say the population is '750 million only' while the 
Ministry of Commerce affirms that 'the number is 830 million.' However, 
the planning department insists that the number is 'less than 750 million.' 
The Ministry of Commerce insists on the bigger number in order to be able 
to provide goods in large quantities. The planning men reduce the figure 
in order to strike a balance in the plans of the various state departments." 

This unusual admission should at least temporarily end the expectation 
that Peking will come up with an official disclosure of China's popula- 
tion. 



POLICIES AND VITAL RATES 

From the above discussion it should be evident that the total 
of 582.6 million reported following the 1953 census represents a rea- 
sonable base for any estimates of China's population, but all the figures 
since then have been either of questionable validity or outright guesses 
by Peking. Despite this paucity of data, it would be wrong to conclude 
that nothing is known about the population of China. Over the years 
there has been considerable amount of data on Peking's attitudes to- 
ward population and on policies and programs that either directly or 
indirectly affect the country's fertility and mortality rates. It is the 
analysis of these policies that makes it possible to speculate on the 
trends of the birth and death rates and to suggest alternative projec- 
tions of the population of China. 

Levels in old China 

In a society where there are no restrictions on reproduction, 
the crude birth rate can be as high as 50 per 1,000 or even higher. 
This has not been the case in China, where traditional customs and 
social forces tending to limit fertility outweighed those which encour- 
aged unlimited families. 

In the past, China has been known to worry about underpopulation. 
The vast territories controlled by the early emperors were, for the most 
part, sparsely populated. More people meant more tax money, larger ar- 
mies, and, finally, greater power. Early marriages were encouraged and 
the Confucian admonition, "To die without an offspring is one of the 



POPULATION DYNAMICS 199 

three gravest unfilial acts," was almost universally accepted, particularly 
since a male child represented the only available form of old-age insur- 
ance. With the extremely high infant and child mortality which pre- 
vailed during most years, a couple needed three sons to ensure the sur- 
vival of one to adulthood; and to have three boys, that family would 
have to have had, on the average, six children. 

On the other hand, there were a number of cultural, social and eco- 
nomic factors throughout China's history which had the effect of limit- 
ing fertility. Considering China's size and the diversity of her popula- 
tion, not all the factors were applicable across the board; but they were 
widespread enough to be significant. Among them were disease and 
malnutrition, which may act to limit fertility; the practice, by certain 
segments of the population, of coitus interruptus; female infanticide, 
thereby reducing the number of women to reach the reproductive" ages; 
the common practice of breast-feeding babies for as long as one to two 
years, which deters conception; inheritance patterns which limited mar- 
riage choices in order to retain family holdings; late marriages delayed 
for financial reasons such as lack of dowry and gifts or lack of money 
for the purchase of brides for the sons; shortage of girls due to prostitu- 
tion, concubinage, and the already mentioned female infanticide; so- 
cial approval of celibacy and disapproval of widows remarrying. Con- 
sidering these inhibiting factors, the historical level of the Chinese 
birth rate for every 1,000 persons was more likely to be in the mid- 
forties rather than the mid-fifties. 

Of particular significance was the practice of infanticide or child ne- 
glect—the postnatal mode of birth control. Although practiced to elimi- 
nate defective and unhealthy offspring, it was primarily aimed at the 
female child who, as a consumer, could be a serious burden to the poor 
family, but because she would leave home on reaching marriageable 
age, she would be useless in perpetuating the family line and in the ob- 
servance of filial piety. The practice of infanticide continued into the 
twentieth century, and as late as 1943 an official publication of the Na- 
tionalist Government exhorted its readers to cease this practice pro- 
claiming the "drowning of girl infants is to be prohibited." Since fertil- 
ity depends not simply on the numbers of people but the number of 
women in the population, the effect of infanticide on population 
growth could be significant. 

Chances are that China's birth rate was more or less stable for many 
centuries with only minor regional variations. But specifically, what 
was the birth rate during the decades immediately preceding the Com- 
munist takeover of the Mainland? Numerous estimates have been 
made; local investigations were conducted in many parts of China, par- 
ticularly in the 1920's and 1930's. In some of the regional surveys birth 



200 MEDICINE AND PUBLIC HEALTH 

rates were sampled directly; in other surveys data on age composition 
were obtained from which approximate birth rates were estimated. The 
differences obtained in these surveys may reflect inaccuracies just as 
likely in the raw data and in the assessment as in the actual rates of 
fertility. Obviously no one knows for sure what the crude birth rate 
was, but probably most authorities would agree that a rate of 40 to 45 
per 1,000 population is a reasonable figure and encompasses most of the 
suggested estimates. 

Whereas the birth rate in China can be considered as high with prob- 
ably only minor fluctuations over the centuries, the death rate is more 
difficult to estimate since it tended to fluctuate between high and very 
high, depending on the extent and intensity of frequent famines, natu- 
ral disasters, military conflicts, and widespread epidemics of such "filth 
diseases" as typhus, cholera, plague, typhoid, and dysentery. For the ov- 
erwhelming majority of the Chinese population, death came without 
any interference from medical personnel, health facilities, or drugs. 
Without straying into a dubious evaluation of the efficacy of Chinese 
medicine, it is fair to say that the small number of legitimate doctors in 
practice were true scholars who contributed to the development, propa- 
gation, and perpetuation of the art over several thousands of years.* 
Unfortunately these few were supplemented by a much larger number 
of "incongruous, diversified, variable, motley group of physicians, 
leeches, empirics and imposters", who gave traditional Chinese medi- 
cine a bad name and, in some areas, a reputation as one of the nine 
lowest occupations in China. 

During the first half of the twentieth century many dedicated people 
worked hard to improve the level of medical care in China. Through 
the efforts of missionaries and, to some extent, the new government in 
Nanking, medical schools were built, public health campaigns were ini- 
tiated, local health departments were established and even the Ministry 
of Health was finally established in 1928. All these efforts, however, 
were rather futile— at best affecting only a small proportion of the 
urban population. Hampered by poor transportation and communica- 
tion, breakdowns in central administration, lack of personnel and 
funds, the general health of the Chinese masses did not improve. 

Since population registers and special surveys are much more likely 
to omit deaths than births, the collected data must always be adjusted— 
another very subjective exercise. According to Ta Chen, who conducted 
an intensive demographic survey of the Kunming Lake Region in Yun- 
nan and supplemented his findings with data from other estimates, the 
1934 national death rate in China was 34 per 1,000 and the infant mor- 



*See Croizier, "Traditional Medicine as a Basis for Chinese Medical Practice," else- 
where in this handbook. 



POPULATION DYNAMICS 201 

tality was 275 per 1,000 births. These figures would seem to represent 
reasonable medians for China, with the death rate dipping into the high 
20's during the better years and rising above the birth rate, for a net 
population deficit, during particularly bad years. 

Because of the fluctuating levels of mortality, an estimate of China's 
rate of natural increase for any one year would be almost meaningless, 
and yet one needs some perspective with which to approach the changes 
that have occurred during the past twenty years. Thus, as a point of ref- 
erence, it is suggested that despite the wars, revolutions, and frequent 
floods and drought, the population of China increased on the average 
of one-half of one percent per year during the first half of the present 
century. It should be remembered, however, that because of favorable 
institutional and economic factors there have been many periods in 
China's history when her population must have increased at a much 
more rapid rate to have overcome recurring major disasters and to have 
reached almost 600 million by the middle of the twentieth century. 

Family Planning— Campaigns and Problems 

When the Chinese Communists took over the reins of gov- 
ernment and set up their new capital in Peking, the size and rate of 
growth of the country's population was undoubtedly not of vital con- 
cern to the new leaders. Furthermore, worry about overpopulation 
would run contrary to Marxist ideology, which attributed human 
misery not to excessive population growth but to the maldistribution 
of income and other supposed defects in the existing social order. 
Since, under the new society, the productivity of the people was sup- 
posed to increase more rapidly than their number, the Communist 
leaders were reluctant to admit that the size of China's population 
could, in any sense, present a problem. They held that the wealth of 
the country was in the hands of the workers and peasants— and the 
larger number of hands could only create greater wealth. 

The results of the 1953 census were completed in the summer of 1954 
and only a couple of months later, in September, the first note of anxi- 
ety was expressed by a prominent member of the National People's 
Congress— Shao Li-tzu. To appreciate the peculiarities of Chinese Com- 
munist etiquette, it is important to distinguish that it was not an 
official concern, but a concern by an official. Although this statement 
was most cautious, he was nevertheless criticized for advocating birth 
control. In his own defense he insisted that the dissemination of knowl- 
edge about contraception had nothing in common with either the old 
or the new Malthusian theory but was necessary to improve the health 
of mothers and infants, to advance the education of children, to allow 
mothers more time for work and study, and in general to provide a hap 



202 MEDICINE AND PUBLIC HEALTH 

pier life for all young men and women. This was to become the basic 
explanation of all future efforts to limit Chinese fertility, for in over 
twenty years there have been only a few statements admitting that a 
large population might have some adverse effects on the country's eco- 
nomic development, with Peking stoutly maintaining that "moderating 
the birth rate is entirely different from restricting population growth". 

Despite a certain sense of indecision, 1955 and 1956 saw a gradual ac- 
celeration in the number of articles that appeared in newspapers and 
magazines discussing the pros and cons of birth control. By the summer 
of 1956 it became clear (although never official) that the birth control 
campaign had authority behind it and that the major responsibility for 
its implementation was assigned to the Ministry of Public Health. In 
August of that year, the Ministry issued a directive which stated that 
"contraception is a democratic right of the people and the government 
should take every step to guide the masses and to meet their demands 
for birth control". The final seal of approval was provided by Chou 
En-lai himself, who, in response to these demands by the people, in- 
cluded in a report to the People's Congress his own demand that health 
departments both disseminate propaganda and take effective measures 
for birth control. 

The campaign, which reached its peak in the spring of 1957, was car- 
ried on with great vigor for a little more than a year. A Birth Control 
Research Committee was set up to "coordinate experience and research 
in contraception," numerous educational campaigns were launched by 
local departments of public health, traveling exhibits were organized, 
and many hospitals and clinics introduced special facilities to give ad- 
vice on birth control. Publications during that period implied that virtu- 
ally everyone was involved, from women's federations, trade unions, 
and the Red Cross Society, to cadres, school teachers and ordinary 
workers and peasants. Abortion and sterilization were reportedly availa- 
ble to couples who made joint application. 

The campaign ebbed, just as it had accelerated, with overlapping ar- 
ticles both favoring and opposing family planning. Gradually the vol- 
ume of arguments against any population controls overwhelmed the oc- 
casional reports of some family planning activities at a given commune 
or plant. With the initiation of communes and the Great Leap Forward 
in mid-1958, it became obvious that Communist China had reversed 
its only recently introduced policy of birth control. A large population 
was once more regarded as advantageous, and the vicious attacks on 
Malthusians, "rightists," and "bourgeois economists" who pushed birth 
control again shifted into high gear. 

The reasons for the 1958 policy reversal naturally precipitated much 
speculation in the West. Was it really possible that the Chinese them- 



POPULATION DYNAMICS 203 

selves believed the proclaimed line that the country was now short of 
manpower? Certainly Communist propaganda had ostensibly succeeded 
in convincing the masses of even stranger ideas and the manpower- 
shortage philosophy meshed nicely, both with the labor-intensive proj- 
ects that occupied every man, woman and child during the Great Leap 
and with the general optimism that permeated the country as a result 
of a successful harvest in the previous year. Nevertheless, it is difficult to 
conceive that the leadership which ordained the reversal was as con- 
vinced of the labor shortage as the mass media would have us believe, 
for the burdens of a rapidly growing population must have been appar- 
ent to anyone with any degree of judgement. 

What might have happened had the euphoria of the Great Leap per- 
sisted is impossible to say. It was predictably of short duration. In 1959 
China entered an economic crisis that focused all effort on survival— a 
dramatic change from the grandiose plans of the year before. For the 
most part there was silence on the subject of population growth but, as 
it turned out, the abandonment of the vocal program of family limita- 
tion was not a complete reversal— it did not result in a campaign to en- 
courage large families. On the contrary, contraceptives, not banned, 
were generally available, although mostly in the cities; birth control 
clinics continued to function; and although facilities were limited, at 
least in theory, abortion and sterilization continued to be legal and 
available for those who requested them. 

Beginning in early 1962, as the country was pulling out of the eco- 
nomic morass of the 1959-1961 period, the Chinese resumed publica- 
tion of articles encouraging family limitation to protect the health of 
the mother and the child. The detrimental effects of early marriage 
were only a part of the earlier birth control campaign; now disapproval 
of early marriage ("a poisonous gas given off by the rotting corpse of 
capitalism") became the primary emphasis of the crusade. By passing 
the Marriage Law of 1950 the Communists had already raised the min- 
imum age of marriage to eighteen for females and twenty for males, but 
at that time the rationale for this law was not demographic; rather, 
it was intended to replace the traditional, early, family-arranged mar- 
riage contracts with unions decided upon by the individuals them- 
selves. The new proposals, by different authors, to raise the optimum 
age for marriage anywhere from five to ten years for both men and 
women, were designed to limit the size of the family. None of these pro- 
posals was legally adopted, but arguments used in the campaign against 
"the evil wind of early marriage" were most imaginative and made fas- 
cinating reading. They ranged from fairly straightforward explanations 
as to why early marriage is "harmful to one's physique, health and ca- 
reer", to scare tactics pointing out how dangerous it is to marry before 



204 MEDICINE AND PUBLIC HEALTH 

"various parts of the body have developed and matured". Simply and to 
the point: "Don't fall in love too early". 

As the general economy showed definite signs of recovery in the mid- 
1960's, the flow of articles on birth control once more slackened and it 
would have been easy but erroneous to have concluded that optimism 
had again eradicated all fears of rapid population growth. Although 
propaganda on birth control and delayed marriage in the mass media 
essentially disappeared, the push for family planning became much more 
action-oriented being directed at the professional medical and public 
health personnel. Articles on the subject in professional journals in- 
creased in number, and medical conferences for obstetricians, surgeons, 
medical administrators, experienced practitioners of traditional 
Chinese medicine, and other medical personnel covered such topics as 
the effectiveness of the intrauterine contraceptive device (IUD) and 
improvement in artificial abortion techniques and sterilization meth- 
ods. Similar meetings at the lower administrative levels (hsien and com- 
mune) included discussions of the practical problems involved in 
working with the peasants. Medical seminars not directed at birth con- 
trol nevertheless usually included this subject on the agenda. 

A most important role in the drive to limit Chinese fertility during 
this period was played by the mobile medical teams, composed of 
groups of urban medical personnel who were required to spend a cer- 
tain part of the year attending to the medical needs of the rural popula- 
tion. Among the duties specifically assigned to the teams, which in- 
creased to over 1,000 by 1966, was the mission to "publicize the meaning 
of planned parenthood among the peasants and propagate the knowl- 
edge about birth control". To accomplish this task members of the 
team conducted propaganda meetings, set up exhibitions, showed films, 
and organized "personal testimony" meetings at which peasant women 
who were using IUD's or other types of contraceptives described their 
reactions— favorable, of course. 

With the advent of the Cultural Revolution, China discontinued 
practically all publications and the few that continued were much too 
pre-occupied with political diatribes even to mention the subject of 
population. After some initial confusion on the part of the Red Guards 
as to whether birth control was "revisionist," it was finally resolved to 
be a Maoist idea and family planning activities initiated in the coun- 
tryside during the previous years were not disturbed. As a matter of 
fact, the thousands of additional medical personnel who were perma- 
nently moved out of the cities during and after the Cultural Revolu- 
tion must have augmented the effort in the rural areas. Moreover, as in 
the case of mobile medical teams, specifically mentioned among the du- 
ties of the barefoot doctors— the thousands of peasants who were given a 



POPULATION DYNAMICS 205 

modicum of medical training and sent out among the masses— was the 
propagation of birth control. This is verified by Edgar Snow who, after 
his 1970 visit to the Mainland, reported that barefoot doctors are also 
"bearers of China's effective birth control pills now in widespread use 
even in rural areas". The continuing push for family planning in the 
urban areas was evident from a January 1970 broadcast that initiated a 
"shock week" campaign from birth control with the announcement that 
"Vigorous efforts should be made to widely propogate birth control and 
late marriage . . . This task must be carried out in a penetrating and 
meticulous manner so that it will reach every household and be prac- 
ticed by each individual". 

Reactions and Results 

What effect did all this action and, at times, inaction have 
on China's birth rate? Trying to convince an overwhelmingly rural, 
poorly motivated, superstitious population that they should delay mar- 
riage and make an effort to limit their number of offspring was not 
an easy undertaking. The difficulty was accentuated by the already 
mentioned traditional Chinese attitude in favor of large families. As 
an outgrowth of Confucian teachings and veneration of ancestors, and 
because of the very practical need for additional family labor, there 
existed an overwhelming desire to betget sons. 

In addition to the problems of motivation and education, there were 
also the physical and economic problems of supplying hundreds of mil- 
lions of persons in the reproductive ages with the necessary parapherna- 
lia for effective birth control. In February 1958 one newspaper admit- 
ted in an editorial that the total supply of contraceptives in China was 
sufficient to meet the needs of only 2.2 percent of all persons in the re- 
productive ages. In other words, even had the Chinese population ac- 
cepted birth control in the decade of the 1950's, given the country's eco- 
nomic priorities, China simply could not have provided the people with 
adequate quantities of contraceptives. 

Thus the fairly extensive efforts to curb Chinese fertility in the 
1950's probably had little effect in the rural areas and only marginal 
success in the cities of China. As a matter of fact it has even been sug- 
gested that there was an increase in the birth rate following the Com- 
munist takeover. Because parental consent was no longer necessary, be- 
cause women were assured that they had equal rights and no longer 
were dependent on either the father or the husband, and because eco- 
nomic security eliminated economic constraints, the marriage rate theo- 
retically could have increased. Actually, however, there is much evi- 
dence that traditional values and customs in China are not put aside 
that quickly and that easily. It takes more than the mere proclamation 



206 MEDICINE AND PUBLIC HEALTH 

of a new Marriage Law for a Chinese girl to practice this strange, new 
emancipation and it seems doubtful that the new freedoms resulted in 
any immediate increase in marriage and fertility among the Chinese 
women. 

Whereas during the 1950's the birth control campaign achieved only 
limited results, it is very probable that during the following ten years— 
the decade of the sixties— the Chinese managed to start a gradual down- 
ward trend in the country's fertility. Considering all the difficulties 
earlier described, how is it possible to suggest such a change in this 
short a time period? 

It is, of course, most important to reach the nation's youth who are 
potentially the most fertile group. In China, people under thirty consti- 
tute approximately two-thirds of the population and, since by the mid- 
dle and late 1960's they had spent most of their young adulthood under 
the Communists, they are also the most thoroughly indoctrinated. Dur- 
ing those years China made significant strides in providing the vast ma- 
jority of the youth with at least a primary level education, so that most 
of the people in the young reproductive ages can no longer be consid- 
ered illiterate. China is poor but not indigent. Some bad crop years not- 
withstanding, improved food distribution procedures have, for the 
most part, resulted in an absence of regional starvation. Even the distri- 
bution of limited consumer goods has improved. For better or for 
worse, political indoctrination and mandatory study of the thoughts of 
Mao have served to avert the intense dejection and desperation so prev- 
alent among many people of under-developed countries. The young 
people of China have been saturated with government policies that den- 
igrate family, cultural traditions and domesticity, but uphold service 
and sacrifice for motherland and socialist conformity— conformity so 
traditional in Chinese society. Because early marriage and numerous 
children are un-Maoist and reactionary, there now seems to be a stigma 
attached to having large families. Given the climate of opinion that 
sees small families as part of a patriotic duty, the youth might well be 
willing to postpone marriage and to accept and practice some form of 
birth control within the marriage relationship. 

Relevant here are the activities (or inactivities) of the Red Guards 
during the Cultural Revolution. Despite some speculation to the con- 
trary, China is one of the few countries in which millions of teenaged 
boys and girls can travel, demonstrate, and sleep under the same roof 
without affecting the country's birth rate. In pre-Communist China, 
premarital sexual intercourse was regarded as extremely reprehensible, 
and chastity held a high place on the list of womanly virtues. This is 
one of the traditions of old China accepted and nurtured by the Com- 
munists and the "liberation" of Chinese women does not extend to the 



POPULATION DYNAMICS 207 

endorsement of free love. All evidence suggests that China's youth con- 
tinue to pursue the puritanical sexual mores of the past. There was 
truly little need for the slogan: "Making love is a mental disease which 
wastes time and energy." 

To be effective, the efforts to limit family size had to go hand-in- 
hand with readily available means for family planning, and contracep- 
tives such as condoms, foams, jellies, diaphragms, and especially intrau- 
terine devices and pills were made more readily available throughout 
the countryside in the 1960's and early 1970's. Birth control pills, so pop- 
ular in the West, are a relatively new phenomenon in China. Al- 
though Chinese medical journals have reported considerable research 
in the field of oral contraception, the limited supply and excessive cost 
hampered mass acceptance and usage of this new drug. More recent 
visitors to Mainland China, however, have reported seeing prominent 
displays of oral contraceptive pills which they claim are in abundant 
supply in China's major cities. Given the necessary priority, China's 
pharmaceutical industry is certainly now capable of producing these pills 
in such quantities as to affect China's birth rate. The remaining ques- 
tions, of course, are whether there is this priority and whether the Chi- 
nese woman— particularly in the rural areas— will adopt this method of 
birth control. According to Edgar Snow, who made a special effort to 
look into these questions during his trip to China in 1970, the develop- 
ments in oral contraception have been dramatic during the past few 
years: the pills are manufactured in the billions, are distributed free of 
charge, and are widely accepted by Chinese women. 

Abortion in China has never faced the moral or legal obstacles preva- 
lent in the West. Nevertheless, although the prerequisites imposed by 
the regime in the 1950's were relatively loose and could easily be met by 
women anxious to terminate pregnancy, the lack of facilities and 
trained personnel made discussions relating to abortions for the most 
part theoretical in nature. Since then the number of induced abortions 
has increased significantly. In the mid-1960's numerous articles in medi- 
cal journals detailed abortion procedures and reported statistical data 
culled from the experiences of individual doctors or medical institu- 
tions. The Chinese are also experimenting with simple methods and 
producing uncomplicated "gadgets" that can be used by lower medical 
personnel in performing abortions in the rural areas. Despite its availa- 
bility, abortion is not really pushed by the regime and although there is 
no way to estimate its incidence, its role in family planning is not 
likely to be very significant. 

Sterilization has never been vigorously promoted by the Chinese 
Communists. First, there is the problem of overcoming the universal 



208 MEDICINE AND PUBLIC HEALTH 

fear of surgery. Second, although it is usually the female who is most 
anxious to take the necessary measures to limit the family, the vasec- 
tomy, or male sterilization, is the easier and cheaper operation. It re- 
quires the most persuasive thoughts of Mao Tse-tung to convince the 
average Chinese male that vasectomy is not castration and that he will 
not experience any loss of sexuality. Third, there is, as in the case of 
abortion, the shortage of hospital facilities and medical personnel to 
perform these operations. Despite these obstacles, sterilization has not 
been ignored. Articles encouraging sterilization and publicizing the 
cases of individuals who have undergone these operations periodically 
appear in newspapers and especially in women's magazines. In the 
1950's, sterilization was a relatively limited urban phenomenon. Al- 
though since then the incidence of sterilization has been increasing 
rapidly, in all probability it is still an insignificant factor in reducing 
Chinese fertility. 

Trying to convert the known policies and attitudes into something 
more tangible is a very subjective exercise. Although opinions differ as 
to how successful China's efforts to drop the birth rate might be, it is 
the contention here that despite the many obstacles impressive progress 
is being made. Furthermore, this conclusion based on the interpreta- 
tion of published data is supported by the reports of recent visitors, 
many of whom made a special point of looking into family planning 
programs wherever they went. Consequently it is estimated that the cur- 
rent crude birth rate in China falls in the 30 to 35 per 1,000 range. If 
this estimate is realistic, it is a tremendous achievement for a country 
that in many ways is still underdeveloped. 

Public Health and Mortality 

Presumably on the basis of sample reporting areas, as in the 
case of the birth rate, the Chinese published a death rate in conjunc- 
tion with the 1953 census activity of 17 per thousand total population— 
a rate that seems much too low for the conditions that prevailed in 
China during that time period. To evaluate this figure and to consider 
the trends in mortality since then, it is necessary briefly to consider 
Chinese policies and practices in medicine and public health during 
the past twenty years. 

The Communists inherited serious health problems when they as- 
sumed control over the Mainland, but they placed a high priority on 
the improvement of the country's health conditions. Lacking personnel 
and facilities for treatment of illnesses, they emphasized preventive 
medicine and sanitation. Millions of people were vaccinated and mass 
campaigns were instituted to improve environmental sanitation and to 
encourage personal hygiene. Millions of people (including children and 



POPULATION DYNAMICS 209 

the aged) were mobilized to participate in the well-publicized campaign 
to exterminate the four pests— mosquitoes, flies, rats, and sparrows— 
and, in general, to clean up the cities and the countryside. With these 
programs, the government did succeed in greatly reducing the occur- 
rence of major infectious and parasitic diseases. 

Paralleling improvements in environomental sanitation and personal 
hygiene were the efforts to increase medical facilities such as clinics, 
hospitals, and sanatoriums, to accelerate the training of medical person- 
nel, and to recast and enhance their traditionally low image. In pre- 
Communist China, the great majority of the 20,000 or so doctors prac- 
ticing Western medicine in the country were trained abroad in Eruope, 
the United States, or Japan. But under the Mao regime, higher educa- 
tion in medicine kept pace with the rapid growth of education in 
general and despite some fluctuations in enrollment and educational 
philosophy, particularly during the Great Leap Forward period, it is 
estimated that by the end of 1966 there were approximately 200,000 
persons on the Chinese Mainland with completed higher medical 
education. 

More important, however, in terms of the country's health, was the 
emphasis the Communists placed on secondary medical education and, 
below that, on a variety of short-term medical training courses for both 
full-time and part-time medical and public health workers. Many of the 
students in these courses were recruited from the countryside, trained 
in nearby commune medical centers and, upon completion of their 
training, returned to their native villages. Obviously with their limited 
training they were unable to perform major surgery, but they could 
provide adequate medical care for the majority of the population and 
in this way overcome the problem faced by other developing countries— 
the difficulty of providing the most basic medical services to their 
rural population. 

During the mid-1960's, in order to disperse medical aid even further 
to the most remote corners of rural China, Peking first introduced the 
mobile medical teams which included the better qualified medical per- 
sonnel to tend the more serious cases during periodic visits to the com- 
munes. The second step was to transfer large numbers of doctors and 
other medical personnel from the cities to the countryside on a more 
permanent basis. And, finally, they instituted a system of politically 
pure "barefoot doctors" who were trained to provide first aid, give inoc- 
ulations, and carry out simple health procedures, and to do all these 
tasks while actively participating in the production activities of their 
work teams. 

Any discussion of medical manpower in China must also include the 
role of traditional Chinese medicine— an empirical healing art based on 



210 MEDICINE AND PUBLIC HEALTH 

thousands of years of practical experience. After an initial tug-of-war be- 
tween medical and political leaders, the latter predictably won and the 
Chinese Communists made an all-out effort to give traditional medi- 
cine equal status with Western medicine. In Peking's view, traditional 
medicine had many outstanding advantages. The training of tradi- 
tional practitioners— "native doctors"— was much quicker and easier 
since it relied on learning from elders and "practicing while learning." 
However, to ensure equal status for both Western and Chinese medi- 
cine, the regime had not only to build up the validity of herb medicine 
but at the same time to deprecate modern medical practices. For this 
purpose, courses in traditional medicine were introduced in all medical 
schools, physicians practicing Western medicine were required to take 
special courses in traditional medicine and both types of doctors found 
themselves working side by side in hospitals and clinics throughout the 
country. Western medical opinion about Chinese traditional medicine 
differs. Some believe it to be little more than black magic; others feel 
that the thousands of herbs and drug potions and the healing arts of 
acupuncture, moxibustion, massage, and breathing therapy have lasted 
all these years because of their empirical value. 

To consider the effects of improved health conditions in China on 
the country's mortality trends, it is necessary to juxtapose the health fa- 
cilities and manpower with the political and economic fluctuations that 
cyclically affect the life (and death) of the Chinese people. 

Probably as early as 1951, China's death rate, which is estimated to 
have been in the low thirties just prior to the Communist takeover, 
started its downward trend. It is inconceivable that it would have 
dropped to anywhere near the 17 per 1,000 reported for 1953, but it did 
continue to decline during the middle 1950's until the introduction of 
the Great Leap Forward in 1958 when it may have been as low as 22 
per 1,000. During the frantic production drive that followed, millions 
of Chinese workers and peasants succumbed to exhaustion due to ex- 
tended working hours, long political indoctrination sessions, and lack 
of sleep and rest. Furthermore, of particular significance in terms of 
health were the conditions at the numerous construction projects, 
which engaged scores of millions of peoples and in which many of the 
most basic sanitary measures were absent. Hard labor, exposure, dirt, 
disease and a poor diet were bound to take their toll and undoubtedly 
negated the favorable effects of the continuing expansion of medical fa- 
cilities. 

During the next three years conditions in China deteriorated rapidly. 
The degree of severity of the lean years following the Great Leap on 
the life and death of the Chinese people is yet another area of specula- 
tion. Although the serious reduction in the production of food crops 



POPULATION DYNAMICS 211 

between 1959 and 1961 and the food shortages that followed are part of 
the known record, the reports of widespread famine by refugees who en- 
tered Hong Kong during these years were probably exaggerated. Never- 
theless, the death rate undoubtedly increased. By 1962 mortality should 
have resumed its downward trend and by the middle of the decade may 
have again reached the pre-Great Leap level. During the Cultural Revo- 
lution the conditions in many parts of China were again unfavorable, 
but because most of the turmoil and reported increases in the incidence 
of some diseases were limited to the urban areas, there was probably 
only a slight pause in the continuing decline in mortality. It is esti- 
mated that by 1970 China finally reduced its crude death rate to about 
15-17 per 1,000— the level reported some seventeen years earlier. 

Barring disasters, natural or man-made, China's mortality should 
continue downward, but very slowly. The decline of mortality in China 
was achieved primarily through the introduction of environmental san- 
itation which tended to decrease vulnerability to death, preventive 
medicine in the form of inoculations and injections, and a large in- 
crease in the number of public health facilities and personnel. A drop 
in the death rate to levels found in more advanced countries is not 
likely for a long time to come. China will continue to be overwhelm- 
ingly rural and the hard work and disabling accidents that occur in tra- 
ditional agricidture are not conducive to longevity. The use of raw 
manure in agriculture will continue. Consequently, elimination of cer- 
tain diseases (particularly of the digestive tract) is virtually impossible. 
In the long run, a continuing drop in the level of mortality would have 
to come about through an improvement in the quality of medical atten- 
tion provided to the people— with more emphasis on the curative rather 
than the preventive approach. With the post-Cultural Revolution em- 
phasis on barefoot doctors and traditional Chinese medicine, and with 
the drastically shortened curriculum for new medical personnel, medi- 
cal care will continue to be more accessible to all, but its quality is not 
likely to show great improvement. 

SOME ESTIMATES AND PROSPECTS 

Having pondered the population data reported by the Chi- 
nese themselves and having speculated on the trends in China's vital 
rates, we arrive face to face with the inevitable question: Just what is 
the population of China? Individuals and institutions in many coun- 
tries have attempted to estimate China's total population. The ap- 
proaches range from outright guesses to application of the most sophis- 
ticated demographic techniques. The validity of all the estimates, how- 
ever, rests in the eyes of the beholder, and caveat emptor hides behind 



212 



MEDICINE AND PUBLIC HEALTH 



every figure. Nevertheless, the most authoritative and the most widely 
used figures are those published by the U.S. Bureau of the Census and 
by the United Nations Population Division. The diversity of the fig- 
ures in the table that follows speaks for itself: 

SELECTED POPULATION ESTIMATES FOR 
THE PEOPLE'S REPUBLIC OF CHINA 

(Population In Thousands) 









United Nations" 






U.S. 


Bureau of the Census 3 


(Medium 


Variant) 


Orleans 






Average 
Annual 




Average 
Annual 




Average 
Annual 






Growth 




Growth 




Growth 


Year 


Number 


Rate 


Number 


Rate 


Number 


Rate 


1960 


718,004 


1.8 







655,000 


1.4 


1965 


782,555 


2.3 


695,000 


1.8 


701,000 


1.5 


1970 


871,035 


2.1 


759,619 


1.7 


753,000 


1.7 


1975 


962,480 


2.0 


825,821 


1.6 


813,000 


1.7 


1980 


1 ,060,695 




893,900 




887,000 





a John S. Aird, Estimates and Projections of the Population of Mainland China: 
1953-1986, U.S. Bureau of the Census, Series P-91, No. 17, Washington, 1968. 
Stagnation model, 5 percent undercount— the series preferred by Aird. 
United Nations, Population Division, Working Paper No. 30, December 1969. 
World Population Prospects, 1965-85 as Assessed in 1968. This is not an official 
document of the United Nations, but rather an internal working paper for 
informational and consultative purposes. 

°These estimates are based on the following general assumptions: (1) The 
reported rates of natural increase between 1953 and 1958 were too high, 
primarily because of an unrealistically low death rate; (2) Starting with the late 
1950s, the birth rate began on a very gradual and hesitant downward trend— a 
trend that will continue during the 1970s; and (3) Despite some fluctuations 
during the 1950s and 1960s, the overall downward trend of the death rate will 
also continue, but very slowly. For a detailed discussion and assumed annual 
vital rates, see my: "Propheteering: The Population of Communist China," 
Current Scene, Hong Kong, Vol. VII, No. 24, 1969. 

Is it possible that in the near future Peking will come out with an 
official series of population statistics and terminate the guessing game? 
At this time there seems to be little prospect for such a development. 
Considering the cost and the effort, it is not likely that another census 
will soon be undertaken while the existing registration system seems 
still to be sputtering and, at best, able to provide only gross approxima- 
tions. Under these circumstances, even should China publish some pop- 



POPULATION DYNAMICS 213 

illation figures, their validity would surely be questioned (especially by 
those whose estimates show the greatest discrepancy) and the dispute 
would continue. 

Thus, the most likely source for improved population estimates is the 
information that might be obtained from more detailed knowledge re- 
garding the status of China's medicine and public health. Peking 
rightly takes pride in China's accomplishments in this field and appar- 
ently is not averse to boasting about them to foreigners. Better statistics 
on morbidity and more first-hand information on family planning pro- 
grams, especially on the receptivity of the population, should provide 
some of the more useful data for any future assessment of the size and 
rate of growth of the population of China. 



NUTRITION 



Samuel D. J. Yeh, M.D. 

and 
Bacon F. Chow, Ph.D. 



About one thousand years before the birth of Christ, nutri- 
tional science began its slow pace of growth in China. During the 
Chou Dynasty (1122 to 249 B.C.), officers were appointed to plan and 
guide the dietary regiments of the ruling emperors and possibly also 
of the people. In the management of the sick, dietary therapy was ad- 
vocated as an integral part of the treatment. During this period of time, 
the world's first nutritional institutions were founded in China. It was 
obvious that early Chinese rulers and scholars realized the importance 
of good nutrition and its implications in building up a stable gov- 
ernment and society. Unfortunately, like many other branches of sci- 
ence in ancient China, the rudimentary development of nutritional 
science was rather short-lived and was not adequately pursued. There- 
fore, many important concepts were never verified and consolidated. 
As centuries passed, many of the early discoveries were often inter- 
mingled with a great deal of superstition and hearsay. 

Through the centuries, Chinese societies were controlled by a minor- 
ity of ruling kings or emperors surrounded by their clansmen and a 
handful of officers. The life and fate of a great majority of the common 
people, largely peasants, were in the hands of the rulers, warriors, or 
those who could grasp power by force. Their fate was also greatly influ- 
enced by nature, by the poverty brought about by famine, flood, 
drought, or epidemics of infectious diseases, and by the incessant wars 
waged by their conquerors. Through the centuries, Chinese writers 
and poets described their society with a sharp contrast of two extremes 
as either "smelling of wines and spoiled meats from the carmine gate" 
or "piling up frozen dead bodies on roads". 

215 



216 MEDICINE AND PUBLIC HEALTH 

In the last few hundred years, with inept and corrupt governments, 
widespread opium addiction, epidemics of a variety of infectious diseases, 
big wars and little wars, famines year after year and general ignorance 
of sanitation, China became a great museum of diseases and poverty. 
In the past, China was noted for high infant mortality, short average 
life span, widespread incidence of infectious diseases and prevalence 
of nutritional deficiencies. Due to a shortage of medical and par- 
amedical personnel, lack of a stable government and unification of the 
nation, there were only a few reliable vital statistics and epidemiologi- 
cal surveys of the incidence of various diseases. At least in certain areas 
of old China, the picture observed by Horn x shows little exaggeration: 

"Poverty and ignorance were reflected in a complete lack of sanita- 
tion as a result of which fly- and water-borne disease, such as typhoid, 
cholera, dysentery, took a heavy toll. Worm infestation was practically 
universal, for untreated human and animal manure was the main and 
essential soil fertilizer. The people lived on the fringe of starvation and 
this also lowered their resistance to disease so that epidemics carried off 
thousands every year. The average life expectancy in China in 1935 was 
stated to be about 28 years. Reliable health statistics for pre-liberation 
China are hard to come by but conservative estimates put the crude 
death rate in times of peace at between 30 and 40 per thousand and the 
infant mortality rate at between 160 and 170 per thousand live births. 
The plight of women and children was bad beyond description. The 
men had to have what grain there was to give them strength to work in 
the fields. The women, especially those who stayed at home to look after 
the children, ate only thin gruel, grass and leaves. They were so ill- 
nourished that by the time they reached middle age, they were toothless 
and decrepit. Many adolescent girls, lacking calcium and Vitamin D, 
developed softening and narrowing of the pelvic bones so the normal 
birth became either impossible or so dangerous that six to eight percent 
of all deaths among women were due to childbirth. Babies were breast 
fed for three or four years, for no other food was available. This threw 
a heavy strain on the mothers, and also resulted in child malnutrition 
and such vitamin deficiency as rickets and scurvy." 

In the 22 years of the existence of the People's Republic of China, 
strides have been made in eliminating a large number of infectious dis- 
eases. As stated in 1959: - "The backward state of health work of old 
China rapidly vanished and an entirely new picture made its appear- 
ance. Cholera has disappeared and notifiable epidemic disease such as 
typhus, relapsing fever, etc., have been brought under control. The 
work of prevention and treatment of parasitic diseases such as schisto- 
somiasis, malaria, filariasis, kala-azar and ancylostomiasis, which used 
to be widely prevalent in our country and a serious menace to health 



NUTRITION 217 

and life of our people, has been carried out with most satisfactory re- 
sults." The interplay between nutritional deficiency and infectious dis- 
eases has been well established. 3 With the control of major infectious 
and parasitic diseases, one would also expect to see a break in the vi- 
cious cycle which results in the development of nutritional defi- 
ciencies. With improvement of transportation, agricultural and in- 
dustrial technology, and mass participation in productive work, the 
age-old food shortages are assumed to have been minimized. As public 
health measures began to be enforced, both in the basic unit of the 
commune in the country as well as in the regimented family unit in 
urban areas, and with the enrollment of the barefoot doctors into 
public health organizations, health programs started to be efficiently 
carried out and government guidelines on family planning 4 to be faith- 
fully obeyed. In return, the general health of large masses of people was 
improved. We have heard from our reporters 5> 6 and visiting scien- 
tists that no frank malnutrition is seen in China today. As a matter 
of fact, interviews with a few emigrants from mainland China also con- 
firmed the impression that overt nutritional deficiency and acute food 
shortages are no longer present in China. With no major wars in the 
past few years and with continuous mobilization of energy to construct 
a Utopia, China certainly has made impressive progress in education, 
public health, agriculture, industry, communication, and in the general 
standard of living for all the people. However, it is not an easy task to 
feed a population of 760 million people who occupy a territory equal in 
size to, but with less arable land than, the United States, and who use 
largely their bare hands and tools comparable to those used in Europe 
and America 50 years ago. Furthermore, with rather generous economic 
aid to many developing countries and with military assistance to quite 
a few costly revolutions, the Chinese people may need to tighten their 
belts in order to share their limited harvests with their friends and 
comrades. Even though visitors have recently seen rosy cheeks on 
Chinese children and strong muscles in the arms of workers and farmers, 
it is possible that nutritional problems will stay with China for some 
time. 

During the 22 years of China's isolation from the world community, 
there have been only a few fragmentary reports available to the West- 
ern world about her scientific achievements. Moreover, with the cul- 
tural revolution, the already limited number of scientific publications 
reached a complete halt. For example, publication of the Chinese Medi- 
cal Journal ceased in 1966 and other specialty journals in medicine 
such as the Chinese Journal of Nutrition, were short-lived. Nutritional 
publications from two well-known nutritional institutes in Peking and 
Shanghai and from other medical schools became scarce. Thus, we 



218 MEDICINE AND PUBLIC HEALTH 

know little about their methods, statistics, or details of their successes 
and failures in science. In the last few years, we heard only indirectly of 
the explosion of the hydrogen bomb, the firing of rockets into space, the 
successful in vitro synthesis of bovine insulin, and various other devel- 
opments. We have heard very little about the well-being of the people, 
young or old, pregnant or non-pregnant, in cities accessible to visitors 
or in regional areas where communication with the outside world is 
difficult. 

We do not know how much nutritional education or programs have 
been undertaken for special groups such as infants, children, pregnant 
women or the elderly. We have the impression that severe deficiency 
states, such as rickets, beriberi, pellagra, scurvy, night blindness due to 
Vitamin A deficiency, kwashiorkor, and marasmus have completely dis- 
appeared from the scene, although we have no data to verify this. We 
know nothing about any large-scale surveys of people in different geo- 
graphic areas to determine nutritional status. However, it is possible 
that large numbers of public health officers have been able to reach the 
rural areas and distant mountainous regions where no medical work 
had every been previously extended. It has been suggested that many 
serious health problems have been prevented as a result of their enforce- 
ment of immunization and birth control and their early recognition 
and treatment of diseases. Nevertheless, it is not clear how much nutri- 
tional education, if any, these paramedical personnel convey to the 
masses of people. Since many nutritional problems may not be as appar- 
ent as those associated with an epidemic of cholera or schistosomiasis, 
one wonders how much priority has been given to nutritional programs 
in national health planning. 

We believe nutrition is a problem of all mankind. The nutritional 
problems which our Chinese colleagues face are important to all men. 
The nutritional problems in mainland China today may differ only in 
degree from what we are facing here in the United States. Unfortu- 
nately, lack of complete information does not permit us to critically re- 
view this subject. Nevertheless, we can undertake a limited review of 
five problem areas in nutrition in the hope that it will stimulate a 
search for answers to some nutritional questions pertinent to all man- 
kind. Specifically, we will discuss the following: first, the importance of 
perinatal nutrition and its implications for pregnant women in 
China; next, some speculation about thyroid problems in China, since 
endemic goiter has been so prevalent in the past; third, the possible 
role of diet and neoplastic disease; fourth, a comparison of estimates of 
general nutritional status with the recommended dietary allowances in 
the United States or with FAO recommendations; and last, speculation 
about the status of nutritional education in China today. 



NUTRITION 219 

I. The Importance of Perinatal Nutrition 

One of the most important problems under study by inves- 
tigators in various health-related disciplines today is the impact of 
environmental conditions, especially in early life, on the physical and 
mental well-being of the human organism. It has become obvious 
through studies in our laboratory and by others that a number of 
factors, among the most important of which is nutrition, contribute 
significantly to the development and to the optimal functional capa- 
bilities of the individual. 

As early as 1789 Malthus 9 stated that the world population increases 
at a greater rate than food sources. The supply of food increases arith- 
metically whereas population growth follows a geometric progression. 
The decline in mortality rates due to advances in medical science and a 
reduction in major wars are probably the main reasons for the high 
rate of population growth. Birth control has been encouraged in 
China. 10 Despite the discouragement of early marriage and wide use of 
contraceptive devices under the strict supervision of health workers, 11 



TABLE I 
Estimation of the number of pregnant women in China 

1. Total population (mid-year) 1970* 759,619,000 

2. Crude birth rate: 1965-1970* 31.1 (high estimate) 

1970** 30.0 (low estimate) 

3. Estimated number of births and pregnancies in 1970: 

High estimate Low estimate 

(1) Live births 25,143,000 22,789,000 

(2) Induced abortions" 5,029,000 4,558,000 

(3) Spontaneous abortions e 2,514,000 2,279,000 

(4) Still births d 1,257,000 1,139,000 

(5) Total pregnancies e 33,943,000 30,765,000 

Notes: 'Population and vital statistics report from United Nations, 1971. 
**Estimated by free hand extrapolation from the past trend. 
"Total population X crude birth rate (high estimate 33 per 1000, and 30 per 

1000 for low estimate). 
"Assuming the ratio of induced abortions to live births of 20:100. 
c Assuming 10 spontaneous abortions per 100 live births. 
"Assuming 5 stillbirths per 100 live births. 
e Sum of all. 



220 MEDICINE AND PUBLIC HEALTH 

the Chinese population is still expanding. The total population in 
mid-1970 was estimated as 759,619,000 (Table 1). The high estimate of 
the crude birth rate from 1965 to 1970 was 33.1 per thousand. By an 
extrapolation from the past trend, the low estimate of birth rate would 
be 30.0 per thousand. Based on a number of assumptions (see footnotes 
to Table 1), it can be estimated that in 1970 there would be between 
31 and 34 million pregnancies and between 23 and 25 million live 
births in China. Therefore, the well-being of 31 to 34 million pregnant 
women every year must be specially considered and a good nutritional 
foundation for 23 to 25 million live babies must be established in 
utero. Provision and proper guidance about good nutrition to pregnant 
women may also minimize the tremendous wastage of pregnancies from 
still-births and spontaneous abortions which can be considered as an ec- 
onomic loss due to the mother's absence from work and need for medi- 
cal treatment. 

The estimate of grain production in China for 1971 was 246 million 
metric tons 12 which probably is sufficient for their nationwide food ra- 
tioning program, as a source of feed for the production of more expen- 
sive animal proteins as well as for the amount of aid to other nations. A 
worker in China is generally granted 60 pounds of rice a month while a 
bureaucrat receives only 30 pounds. Meat, eggs, and vegetables are not 
rationed, but their supplies may not be very plentiful. In general, we do 
not expect Chinese families to have bacon and eggs at breakfast and 
steak at dinner. Their fat intake is low and sources of animal protein 
are scarce. Assuming a daily intake of 500 grams of rice per person per 
day, one may estimate intakes of approximately 1800 calories, 40 grams 
of protein, 400 grams of starch, 120 mg of calcium and 700 mg of phos- 
phorus. If no other food stuffs are provided, such a dietary allowance 
may be barely sufficient to support sedentary activity but not sufficient 
for the strenuous physical work in which most people must participate 
in the fields or factories. Such a dietary intake would be grossly inade- 
quate for providing expectant mothers with enough calories, proteins, 
minerals and vitamins to meet the increased demands for growth of the 
foetus and her tissues during the gestation period and for production of 
breast milk of adequate quantity and quality needed by the infant dur- 
ing the critical period of physical and mental development shortly after 
birth. It is well known that the nutritive value of grain proteins is 
much inferior to that of animal proteins. The protein from rice is defi- 
cient in lysine, but lysine supplementation of rice has not been advo- 
cated in China. A qualitative and quantitative deficiency of good pro- 
teins during the perinatal period is potentially dangerous since it may 
cause irreparable damage to these 23 to 25 million babies. China is a 
very large nation in which geographical factors vary greatly from one 



NUTRITION 221 

area to the other. Despite the impressive estimates of steel, cotton, fer- 
tilizer and grain production, 13 we believe that a large portion of the 
population still lives in some of the less fortunate geographic areas, 
comparable to our Appalachian areas, where people must subsist on 
whatever their barren land can provide. One wonders if nutrition of 
pregnant women in these areas may be receiving any special attention 
by the Chinese leaders and nutritional experts. 

II. Thyroid Disorders 

Thyroid disturbances have attracted the attention of many 
nutritionists in the past. It has been estimated that there are still about 
200 million people with endemic goiter in the world. 14 The evidence 
to support iodine deficiency as the cause of endemic goiter was ob- 
tained from epidemiological studies 15,16 and studies in experimental 
animals. 1718 It has been unequivocally demonstrated that iodization 
of table salt can effectively eradicate the development of goiter in the 
endemic areas. 19 

The earliest reference to goiter in the Chinese literature was found 
in Chuang Tze written by Chuang Chow in the third century B.C. 20 In 
the same century goiter was recognized as an endemic disease by Lu Pu 
Wei in Lu Lan. The ancient Chinese also observed that goiter was pres- 
ent in the mountainous areas as described in Shan Hai-Ching, the 
book of mountain and sea, which was said to be written by Po Yi in the 
reign of Shi Yu during the interval of 2205-2198 B.C. The first classical 
description of the disease appeared in the year 610 A.D. in Chao's 
General Treatise on the Etiology and Symptoms of Disease. The early 
Chinese Physicians knew that seaweed (Hai Tai, Laminarias) had a 
beneficial effect on goiter. In the third century, Ke Hung (281-261 
A.D.) prepared an alcoholic extract of Hai Tsao (Sargassum siliquas- 
tuum) for goiter. In the sixth century, sheep thyroid gland was used in 
the treatment of cretinism. In The Private Prescriptions of An 
Official written by Wang Tao, seven prescriptions out of 36 were found 
to contain seaweed or other marine products. In the twelfth century, 
Change Tsung Chen in his book Literate's Care of Their Father, 
even recommended soaking seaweed in the drinking water for prophy- 
laxis of goiter. Therefore, it is apparent that recognition of the goiter 
problem by the Chinese was somewhat earlier than that in the Egyptian 
and Roman medical scripts which were probably written about 700 
B.C. The use of iodine in the treatment of goiter was not recorded 
until the publication of Prosser in 1769. 21 The concept of iodine defi- 
ciency and its pathogenesis was first suggested by Marine in 1909. 22 

J. S. Horn stated in his book: 1 'Another example of preventive work 
is the prevention of goiter, which formerly affected most adults in some 



222 MEDICINE AND PUBLIC HEALTH 

villages. The main cause, lack of iodine in the drinking water, has now 
been remedied by addition of an iodine compound to table salt. As a 
result goiter is now less common and in time it will disappear." We be- 
lieve this is an oversimplification of the goiter problem in China. Io- 
dine metabolism and goiter development are rather complicated prob- 
lems. Even with much more active programs of goiter prevention in 
many centers of endemic goiters in the world, such as in the region of 
the Alps, of the Great Lakes in the United States, in Lima, Peru, and in 
certain regions in British Columbia and Canada, complete eradication 
of endemic goiter has not been achieved. Iodization of table salt was 
started in China long before the founding of the People's Republic, yet 
in the studies of 1950, adults in the Tushan mountain regions of Hopei 
Providence 23 showed a goiter incidence of 42.3% among 979 males ex- 
amined and 55.4% among 971 females examined, with an average inci- 
dence for both sexes of 48.8%. The section on endocrine and metabolic 
diseases of Peking Union Hospital and the Chinese Academy of Medical 
Sciences in Peking summarized the collaborative studies 24 in seven prov- 
inces, viz., Hopei, Honan, Shansi, Kirin, Kansu, Hupeh and Hunan in 
which 7,585,000 individuals were examined and 592,700 goiters were 
found, an incidence of 7.8% (Table II). The lowest incidence, found 
in Kirin, was 2.8% and the highest, in Hsu Kou Hsiang in Kansu Prov- 
ince, was 82.3%. In one of the villages in Changchiakou, Hopei, the io- 
dine content of the drinking water was 0.27—0.6 ug/L and the goiter 
incidence was 40.1%; in a second village, the iodine content was 3.44 
ug/L and the goiter incidence was 33%. It was also demonstrated that 
about 58% of the inhabitants subsist on a water supply with less than 1 
ug of iodine/L and that the goiter incidence varied from 19.1 to 40%. 
The distribution of iodine, however, varies tremendously and some 
wells in these villages were found to have iodine concentrations of 
about 5 ug/L. This finding does not surprise us. Percolation of the 
water, alkalinity of the soil, cropping of the vegetation and catalytic ac- 
tion of certain substances such as iron and manganese, which tend to 
liberate iodine in volatile form from the soils, tend to deplete the soil 
of iodine and influence iodine content of the drinking water. 

In one study, 25 the iodine content of water, soil, and food in an en- 
demic area of goiter in Shansi Province was given (Table III). Some 
correlation was found between the iodine content of drinking water 
and the rate of goiter. It is also of interest to note that the calcium con- 
tent in the area with high goiter incidence was higher while the magne- 
sium content was lower than those in an area with lower goiter inci- 
dence (Table IV). 

We do not know whether other endemic areas have been also exten- 
sively surveyed to an extent comparable to what in Yi Hsien, Hopei 



NUTRITION 



223 



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MEDICINE AND PUBLIC HEALTH 



Table III 
The Iodine Content of Water, Soil, and Food and the Goiter Rate in Parts of Shansi 







Area of low 
Iodine 


endemicity 
Goiter 


Area of high 


endemicity 




Iodine 


Goiter 






ug/L or kg 


Rate % 


ug/L or Kg 


Rate % 


River water 




6.53 


26.1 


3.59 


56.4 


Spring water 




3.88 


40.2 


2.53 


59.0 


Shallow well 


water 






3.42 


63.7 


Deep well water 


7.53 


35.0 


3.46 


58.3 


Stream water 




2.58 


19.8 


4.19 


60.6 


Soil 




4025 


33.6 


3395 


60.6 


Corn 




263.6 




132.7 




Millet 




244.4 




156.7 




Sorghum 




295.6 




176.3 




Wheat 




160.8 




140.7 




Soybean 




160.8 




123.5 





(Han, S. C, et al., M. J. Shansi 2:10, 1958) 



Table IV 
Mineral Analysis of Water Supply in Parts of Shansi 



Area of low 

endemicity 

mg/L 



Area of high 

endemicity 

mg/L 



Iodine 

Manganese 

Calcium 

Magnesium 

Fluoride 

Chloride 

Carbonate 

Total Hardness 



0.00513 
Trace 
59.67 
20.13 

0.12 
20.67 
10.96 

10.38 



0.00350 
Trace 
88.80 

6.38 

0.10 
19.10 
11.80 

13.06 



(Han, S. C, et al., M. J. Shansi 2:10, 1958) 

and Nan Yang, Honan where the total population of six million people 
were examined. It is well known that endemic goiter is widely distrib- 
uted in China and that mountainous districts and inland areas are 
those usually affected to the highest degree. Data from the interior part 
of China were not available for this report. In Yunnan province, the 
incidence of goiter was found to be as high as 80% among the total 
adult population in some areas. 26 The iodine content in the salt in 
these areas was only 22 parts per 1000 million as compared to a content 
of 5100 parts per 1000 million in Szechwan. We would be very doubtful 
that all endemic goiter has been completely eradicated in these areas 



NUTRITION 225 

even though the program of supplementation of salt with iodine had 
begun in 1941. 26 

It is known that the requirements for iodine are related to many 
physiological and environmental factors. The requirement is high dur- 
ing adolescence, and particularly during pregnancy, lactation and even 
menstruation. The measurement of thyroid enlargement of a popula- 
tion without regard to age, sex, or physiological status is therefore 
somewhat misleading. A consideration of these variables would be ap- 
propriate. 

From metabolic balance studies, 27 it was well established that iodine 
deficiency in endemic goiter in man was due to dietary deficiency of io- 
dine rather than to excessive urinary and fecal losses. It should be 
pointed out that not all subjects in an endemic area with iodine defi- 
ciency will develop goiter. Most individuals in these areas will excrete 
less than 40 ug of iodine per day and have a plasma inorganic iodide 
below 0.08 ug per 100 ml. 28 However, complete correlation of dietary io- 
dine deficiency and urinary iodine excretion may not always occur in 
some endemic areas. 29 From field studies in Thailand, Follis 30 believed 
that an iodine content of less than 50 ug/mg creatinine in a random 
urine sample was an index sensitive enough to suggest iodine defi- 
ciency. Data on the kinetics of iodine uptake, using radioactive tracers, 
were obtained in many field studies on endemic goiter in many parts of 
the world. However, this type of study has not been carried out in the 
endemic area of China. More recently, increases in immunoreactive 
thyrotropin were found in serum of some patients with endemic goi- 
ters. 31 ' 32 ' 33 This finding is probably a reflection of adaptation to low 
iodine intake by a hypersecretion of thyrotropic hormone, which may 
increase the efficiency of the iodine-trapping mechanism of the thyroid 
in order to maintain normal thyroid hormone levels. We believe that 
future surveys should be extended to include detailed analyses of food, 
water, body fluids, tissues removed at operation or autopsy, and possibly 
also iodine kinetic studies in different age groups with deficiencies of dif- 
ferent severity and with different responses after treatment. Informa- 
tion about thyrotropin levels in responses to TRF (thyrotropin releas- 
ing factor, 1-Tyroglutamyl-l-histidyl-l-proline amide) to evaluate 
the hypothalamic-pituitary axis in individuals from endemic areas will 
also be useful. 

In addition to iodine deficiency, the amounts of other minerals in 
water and food must be also considered. High calcium 34 and fluoride 3S 
content in the diet have produced goiters in experimental animals. 
High incidences of goiter in England and Scotland were thought to be 
attributed to the high calcium content of the drinking water. 36 In the 
studies cited above in Shansi province, where a high incidence of goiter 



226 MEDICINE AND PUBLIC HEALTH 

was found, the calcium content of the drinking water was also higher 
than that from the areas with a low incidence of goiter. More extensive 
analyses of this kind woidd be necessary to further clarify this relation- 
ship. 

The fist of known goitrogens is lengthening. Cauliflower, turnips, 
soybean, peaches, pears, spinach, carrot and strawberries are known ex- 
amples. Since Chinese herb medicines have been very much popularized 
since the cultural revolution, we do not know how many of these 
herbs would bring about disharmony of the "yin and yang" of our thy- 
roid gland. Cow's milk and milk products are not popular as infant 
foods in China, at least not in rural areas. Most milk substitutes are 
made from soybean. It was reported that soybean milk may produce goi- 
ter in children and that this development can be prevented by an in- 
creased iodine intake. 37 A continuing search for and isolation of natu- 
rally occurring goitrogens in certain endemic areas is very important. 

Associations with cretinism and deafmutism were said to be fre- 
quently found in patients with endemic goiter in the Himalayan areas 38 
but were not found elsewhere. 39 Cretinism was very common in areas of 
goiter endemic in Yunnan province. 26 In one mountainous district in 
Hunan, the incidence of goiter among 619 inhabitants was 77.7% 40 
and that of cretinism was 1.7%. In the areas of Kansu province with a 
total population of 422,181, goiter was found in 31% of the 130,581 in- 
dividuals examined but the rate of cretinism was only 0.33%. 41 Hyper- 
thyroidism was not common in Yunnan but was high in the cities along 
the China coast. For example, toxic goiter represented 25% of the cases 
of thyroid enlargement in Changchow, 65% in Peking, 78% in Canton 
and 100% in Shanghai. 26 It is our impression that Chinese immigrants 
in the eastern part of the United States also have a high incidence of 
thyrotoxicosis. It is impossible to have reliable statistics since the sam- 
ple size is rather small and the immigrants came from various parts of 
Mainland China and have stayed here for variable amounts of time. It 
is not clear whether this trend of high incidence is related to iodine 
deficiency at some time in their life or is related to some unknown en- 
vironmental factors. 

The high cancer rate in Bern and Lebanon where endemic goiter is 
prevalent was not seen in other endemic areas. 42 - 43 ' 44 Patients with fist- 
or head-sized colloid goiter could be found easily in Kunming and in 
neighboring cities in the Yunnan province before 1945. There was no 
mention about the incidence of thyroid neoplasms in case of endemic 
goiter surveyed in China. 24 - 25 - 26 In Taiwan, among 2,943 autopsies per- 
formed between 1946 and 1963, carcinoma of the thyroid was encoun- 
tered in only two cases, representing an incidence of 0.1%, in contrast 
to 9 cases of thyroid cancer among 766 autopsies from Columbia Presby- 



NUTRITION 227 

terian Medical Center from 1953 to 1954, with an incidence of 1.2%. 45 
In approximately the same period, namely from 1949 to 1962, thyroid 
cancers were found in 496 patients of a total of 27,000 cases entered in 
the tumor registry at Memorial Hospital in New York. 46 Regardless of 
the percentage incidence, thyroid cancer in endemic areas of various 
parts of China probably is not a serious problem. 

In summary, we believe that the goiter problem has not been com- 
pletly eradicated in Mainland China. More extensive epidemiological 
and nutritional surveys in various parts of interior China, using more 
sensitive biochemical, immunological and radioisotopic methods, 
would be very rewarding. 

III. Nutrition and Cancer 

Nutritional habits have been long thought to affect the 
pathogenesis of cancer in man. In experimental animals, caloric, pro- 
tein, or fat intake, imbalance of essential amino acids, or deficiency 
in certain vitamins or minerals can influence the induction or growth 
of tumors. 47 Dietary deficiency, particularly protein deficiency, has 
been shown to increase host susceptibility to a variety of carcinogens 48 
including aflatoxin. 49 It is also known that dietary manipulations in 
animals may greatly alter the drug metabolizing enzymes in the smooth 
membrane of the endoplasmic reticulum of liver 50 and possibly also 
of the gastrointestinal tract 51 which may thus potentiate 52 or inacti- 
vate 53 a large number of carcinogens. With the exception of an asso- 
ciation between kwashiorkor and hepatoma in Mozambique, Uganda 
and South Africa, 54 epidemiological evidence relating nutrition to 
cancer cannot be readily obtained. However, the marked differences 
in the incidences of different types of cancer in different geographic 
areas as reported elsewhere in this publication prevent us from ignoring 
the possible role of nutrition in the pathogenesis of various types of 
cancers. Obviously, differences in the dietary habits in such different 
geographic areas must be considered as one of the possible environ- 
mental factors in the pathogenesis of neoplasms in different anatomical 
locations. With the reported gradual improvement in transportation 
and with it the movement of large segments of the population from 
one area to another in China during the last few years, we wonder 
whether the trends in geographical differences in various cancer in- 
cidences will eventually disappear. 

With most infectious and parasitic diseases under control, Chinese 
health workers are now faced with the challenge of eliminating cancer, 
rheumatic heart disease, coronary artery disease and hypertension. As 
pointed out by Dimond after his recent trip to China, 55 "Cancer is a 
major dread, and there is an increased incidence in the nasal passages, 



228 MEDICINE AND PUBLIC HEALTH 

esophagus and liver." Of course, it is always difficult to determine 
whether these observations represent a real trend of increases of inci- 
dences of these neoplastic diseases or merely a reflection of improve- 
ments in diagnostic skills, statistical accuracy and extension of better 
medical care to wider areas of the nation. 

In China, cancer of the uterus, particularly cancer of the cervix, rep- 
resents 14.7% of all cancers. 56 On the basis of statistics reported on 
1959 it was the malignancy of highest incidence in four large cities, Pe- 
king, Tientsin, Sian and Shanghai. There was no evidence to suggest 
that overweight or a change in basic nutrition played any important 
role in the pathogenesis of this neoplasm. It is of interest to point out, 
however, that studies by Wynder et al. 57 demonstrated an increased risk 
of developing endometrial cancer in overweight individuals. The inci- 
dence of endometrial cancer increased among the Japanese when they 
moved to Hawaii and California and their fat consumption increased 
from 10 to 40% of total calories and changed from primarily unsatu- 
rated fat to saturated fat. 58 It would be of interest to find out whether 
the mass movement of an urban population to a rural area in China 
today would slow down the trend of an increased incidence of endo- 
metrial cancer which may have resulted from urbanization of life styles 
and perhaps overnutrition. 

Carcinoma of the esophagus is one of the most prevalent types of can- 
cer in North China. According to the vital statistics from Peking and 
Tientsin for the years from 1958 to 1960, the incidence of carcinoma of 
the esophagus was second highest among all cancer deaths. 56 In the male 
population, esophageal cancer was first in order of frequency for all 
deaths due to malignancy. Using the people's commune as the basic 
unit, all people over 30 years of age were interviewed and all persons 
with discomfort in swallowing food were examined thoroughly. In four 
provinces with high esophageal carcinoma, namely in Shantung, Hopei, 
Shansi and Honan, the highest rate was that Lin Hsien of Honan " 7 
with an incidence of 67.26 per 100,000 and the lowest was that from the 
Yentai district of Shantung, viz., 0.32 per 100,000. Rates were higher 
in the rural and mountainous areas than in the cities. 

In this rather extensive study, involving over seventeen million in- 
habitants, no nutritional history was given. However, it is of interest to 
note that a family history of cancer of the esophagus was found in 
61.4% in Lin Hsien, Honan where the annual incidence of cancer of 
the esophagus in 1960 was 96.9 per 100,000; 24.0% in Shantung prov- 
ince with an annual incidence of 3.24 per 100,000 and in patients in 
Shansi province with a rate of 19.69 per 100,000. In the epidemiological 
studies by Wynder 59 and Schwartz, 60 high correlations between alcohol 
consumption and cancer of the oral cavity, extrinsic larynx, and esopha- 



NUTRITION 229 

gus were noted. The percentages of alcohol drinkers among patients 
with cancer of the esophagus in this study from North China varied 
from 28.8 to 45. 1%. 61 In Feicheng of Shantung, the incidence of cancer 
in 1960 was 77.8 per 100,000 but the percentage of alcohol drinkers was 
only 28.8%, which is lower than the incidence of alcoholic drinking in 
the entire Shantung province. Furthermore, the highest incidence of 
cancer of the esophagus was found in Lin Hsien, Honan, but there was 
practically no alcoholic drinking among the population. Certainly, al- 
cohol alone does not seem to be a very important factor in the pathogen- 
esis of cancer of the esophagus in North China. 

In riboflavin deficient mice, atrophic changes and hyperkeratosis 
were found in the esophagus. 62 Wynder thought that such a degenerated 
esophagus may be more susceptible to environmental carcinogens. As a 
matter of fact, riboflavin deficiency is not the only condition which 
brings about degeneration of the upper alimentary tract. In our pre- 
vious studies in rats, 65 we demonstrated that pyridoxine deficiency can 
bring about decreases in vitamin B 12 absorption, intrinsic factor pro- 
duction and gastric acid secretion. Likewise, iron deficiency 64 may also 
cause such changes. It is not clear whether any of these deficiencies may 
make individuals more susceptible to certain carcinogens in Honan, 
Shansi, Hopei and Shantung with incidences of cancer among the sur- 
veyed population of 41.05, 19.69, 8.14, and 3.24 per 100,000, respec- 
tively. 61 To what degree the difference in dietary habits between the 
North and South could be responsible for differences in the incidence 
of cancer of the esophagus, which was the second most frequent malig- 
nancy in Peking for the year 1964 but only the fourth most frequent 
neoplasm in Shanghai in the year 1965, is not clear at present. 

Cancer of the stomach in China is probably not as frequent as in 
Japan. It is, however, the second most common malignancy of the gas- 
trointestinal tract and represents about 40 to 50% of all gastrointes- 
tinal cancer. In studies in the United States, a relatively high incidence 
of cancer of the stomach was attributed to the early loss of teeth. 65 A 
reduction in the intake of potatoes and an increased consumption of 
fresh fruits and vegetables were reported to be associated with a de- 
creased incidence of cancer of the stomach in this country. In China, 
periodontal diseases are very common, but serious dental caries with 
early loss of teeth is not frequent. 

Cancer of the colon and rectum represents only 10 to 20% of all can- 
cer of the gastrointestinal tract in China. In the United States, the 
incidence of cancer in this location is 60 to 70%. The sharp increase in 
the incidence of colon cancer among the Japanese immigrants in Ha- 
waii and California suggested that changes in dietary patterns may 
have been responsible for the increased incidence. 66 Furthermore, a pos- 



230 MEDICINE AND PUBLIC HEALTH 

itive correlation between colon cancer and arteriosclerotic heart disease 
was demonstrated and presumed to be related to the fat intake. 67 

Cancer of the nasopharynx is a disease very common in South China. 
In the past few years, about 12,000 cases were reported in 47 cities. 68 Ac- 
cording to the tumor registry in Shanghai in 1965, this was the eighth 
most frequent malignancy in that region. Low levels of Vitamin A and 
carotene in serum were found in patients with nasopharyngeal cancer 
in Kenya. 67 There is so far no data from China to suggest this relation- 
ship among Chinese patients. The incidence of this disease in the sec- 
ond or third generation in California has decreased markedly. 

Primary cancer of the liver was the 5th most common malignancy ac- 
cording to the tumor registry of Shanghai in 1965. An association be- 
tween protein malnutrition and hepatoma was common in patients in 
South Africa 54 and severe malnutrition and alcoholic cirrhosis were 
common in patients with hepatoma in the United States. 69 Apparent nu- 
tritional deficiency and chronic alcoholism were not apparent in the 
Chinese patients from any of these studies. It was well demonstrated 
that parasitic infestation such as with Clonorchis sinensis was present 
in approximately 60% of all cholangiocarcinoma in Hong Kong 70 but 
not in liver cell carcinoma. It was also suggested that schistosomiasis ja- 
ponicum may be related to hepatoma. 71 However, areas with a high in- 
cidence of hepatoma, such as Hong Kong or Taiwan, are not endemic 
areas for schistosomiasis. The distribution of hepatoma along the 
China coast was found not related to endemicity of schistosomiasis. 
Furthermore, with the reported eradication of schistosomiasis in China, 
the incidence of hepatoma appears to be increasing. 55 Therefore, nutri- 
tional deficiency, secondary to parasitic infestation, does not seem to 
play any important role in the pathogenesis of hepatoma in China. 

In experimental animals, nutritional factors play very important 
roles in the induction and growth of chemically induced hepatoma. For 
example, choline deficiency in rats resulted in cirrhosis and hepatoma. 72 
Diets low in protein and riboflavin increased the rate of development 
of dimethylaminoazobenzene-induced hepatoma, 73 whereas administra- 
tion of cysteine, methionine, or choline often retarded tumor develop- 
ment. 74 An imbalance of amino acids may also increase carcinogenesis 
in rats since addition of lysine to gluten or zein increased the incidence 
of dimethylaminoazobenzene-induced hepatoma in rats. 75 Of many nat- 
urally occurring carcinogens, such as cycad seeds, 76 yellow rice contami- 
nated with Penicillium is Ian di cum, 77 bush teas, 78 senscio alkaloids, 79 and 
wheat or peanut meal contaminated with fungus Asperigillus flavus, af- 
latoxin Bl, 80 the last one probably has received the most attention in 
the past few years. Aflatoxin-containing meals have been shown to be 
hepatoxic to many species of animals and susceptibilities vary greatly 



NUTRITION 231 

with age, sex, nutritional status, species and bread. Young animals are 
more susceptible than adults. Animals during late stages of pregnancy 
are also very susceptible. 81 Hepatoma was produced by feeding 
aflatoxin-containing meals to rats, ducklings, trout, guinea pigs, and 
monkeys. The susceptibility was greatly increased with protein defi- 
ciency and the development of hepatoma was often associated with the 
presence of previous liver damage. 82 Since Asperigillus flavus grows in 
an environment with high temperature and humidity, contamination 
with aflatoxin of animal and human foodstuffs is particularly common 
in tropical and subtropical areas where the hepatoma happens also to 
be prevalent. In Taiwan, some asperigillus species are used to make soy- 
sauce. It has been stated that some individuals may consume about one 
liter of soy sauce per month. 83 Aflatoxin extracted from commerically 
available soy sauce and approximately equal in amount to that ordinar- 
ily consumed per week per person caused hepatic parenchymal hemor- 
rhage and bile duct proliferation in a one-day-old duck. 83 Although 
there is no unequivocal evidence that aflatoxin is responsible for the 
high incidence of hepatoma in man in certain areas of the world, the 
significance of mycotoxins and possibly of other naturally occurring car- 
cinogens in the etiology of human disease cannot be overlooked, partic- 
ularly in populations with suboptimal nutrition. 

IV. General Nutritional Status 

In a previous section, we stated that with a rice ration of 
30 pounds per month, each person would get 1800 calories, 40 grams 
of protein, 400 grams of starch, 120 mg of calcium and 700 mg of 
phosphorus. The food intake of a middle class family in the Peking 
area was estimated to be 2500 calories per person per day 84 which does 
not differ from the recommended values. For example, the National 
Research Council recommended 2800 calories for men and 2000 cal- 
ories for women. 81 Even a completely vegetarian diet supported ade- 
quate growth in experimental animals. 86 Food and nutritional prob- 
lems in China were carefully analyzed by Buck. 87 Arable land was 
estimated to be about 11% of the total surface, i.e., about 35 mil- 
lion acres. 87 On the basis of incomplete data, it is estimated that the 
food intake per capita per day during the period of 1935 to 1957 was: 
500 grams of grain, 4 grams of sugar, 140 to 350 grams of vegetables 
and fruits, 12-16 grams of meat, 13 grams of fish, 7-8 grams of fat, and 
total calories about 1830 per day. 88 We do not know precisely the pro- 
tein intake of the average person in Mainland China. In Taiwan, it 
was estimated that protein intake was 57 grams per day, with only 25% 
from animal sources. 89 It is known that the efficiency of production of 
animal protein from plant sources is rather low. 90 Because of this and 



232 MEDICINE AND PUBLIC HEALTH 

because the percentage of arable land is low, it may be very difficult 
for the average Chinese to change his diet from one with a low amount 
of protein of poor quality to one which includes a high amount of 
animal protein which has high nutritive value. 

We have already emphasized the possible impact of good protein in 
the maternal diet on the physical and mental development of the off- 
spring. The fat in the Chinese diet contributes only 10 to 20% of the 
total calories. Such a low fat content may be advantageous in delaying 
the development of obesity, hypertension, arteriosclerotic heart disease 
and endometrial carcinoma. In the Chinese diet, vegetables contribute 
about 220 mg and cereal products 100 mg of calcium. Milk or milk 
products with high calcium contents are generally not available to the 
average Chinese, even to the newborn in the rural areas. It is estimated 
that retention of 400 mg of calcium per day is necessary for adequate 
mineralization of the growing skeletal system and approximately one 
gram of calcium per day is necessary for such retention. Therefore, 300 
to 400 mg of calcium per day is probably not sufficient, particularly dur- 
ing pregnancy and lactation. In adults with adequate parathyroid func- 
tion and sufficient exposure to sunshine to convert provitamins in skin 
to Vitamin D, body homeostatic mechanisms may adapt to low calcium 
intake, and show no evidence of deficiency. In old people, where hom- 
eostatic functions may be defective, a low intake of calcium may cause 
problems. The calcium intake of the Chinese appears to be low and 
could be increased by the consumption of more meat, fish, poultry, and 
milk products. Even with erratic intakes of meat and eggs, the supply of 
fat-soluble vitamins in the Chinese diet is probably sufficient. If our as- 
sumption is correct that the supplies of fresh vegetables and fruits are 
ample, Vitamin C and folic acid intakes probably will be adequate. We 
do not know whether vitamin enrichment of cereal products has been 
carried out in China. In the old Chinese society, only poor farmers 
would eat partially polished rice and most thiamine is contained in the 
bran. With modern improvements in cooking utensils, it is no longer 
necessary to discard the vitamin-rich rice water in the process of mak- 
ing steamed rice. Therefore, we believe that the intake of the B-vita- 
mins is probably adequate in the Chinese diet. As for iron intake, it is 
probably not difficult to obtain 10 mg of iron per day in the diet to 
meet the requirement of 1 mg of iron per day for men and 2 mg per day 
for woman. However, it is known that the availability of iron com- 
pounds from different foods is not uniform and that animal foods are 
superior sources of iron. In old China, iron deficiency anemia was often 
caused by hook worm infestations. With the eradication of this parasite, 
and the lack of clay-eating habits among the Chinese, the iron require- 
ment could be easily met. In general, we believe that the diet for the 



NUTRITION 233 

average Chinese person is not inadequate. The increased intake of 
proteins of high quality and of calcium for special age groups during 
specific periods require consideration. We hope that data from quan- 
titative analyses of food intake of different age groups from various 
geographic areas and assessment of nutritional status with respect to 
protein, fat, minerals, and vitamins of these groups of people will be 
available in the near future. 

V. Nutritional Education in General 

In the United States, nutritional sciences have not been well 
incorporated in the medical curriculum. Very few medical students 
have been exposed to basic nutrition. We doubt that nutritional edu- 
cation of the medical and paramedical personnel in mainland China 
is adequate. Before the pre-liberation period, there were only about 
20 to 35 thousand Western-trained physicians 91 and perhaps less than 
10 nutritionists in all of China. With shortening of the duration of 
medical education, and the involvement of medical students in many 
political and social activities, these students must spend their already 
limited time in digesting the vast amount of material on various med- 
ical subjects, and have very little or no time for studying nutrition. In 
the new curriculum of medical education, only one coordinated course, 
which combines anatomy, physiology, biochemistry, Chinese traditional 
medicine, and Political Education, will be given the first nine months. 
Reinforcement of basic science, incorporated with clinical experience, 
may be added in later months, with the total duration of medical ed- 
ucation equal to three years. How much nutritional knowledge can be 
acquired by the students with such limited time is really questionable. 
Checking all books on medical and nutritional subjects in the Chuan 
Kuo Hsin Shu Mu (Chinese National Bibliography, Peking) from 1958 
to 1966, we found translations of the major textbooks in Medicine, 
Surgery, Radiology, Radiotherapy, Physiology, Biochemistry, Anatomy, 
and Radiation Physics commonly used in this country. However, no 
translation of any classical nutritional textbook was available. There 
were 16 monographs on general nutritional subjects. These were: 
"Food and Nutrition" by Fan Wen-Yuan; "Practical Nutrition of 
Children" by Su Tsu-Fei; "Contributions by Modern Native Physiolo- 
gists and Modern Chinese Nutritionists" by Wu Hsiang; "Nutrition 
for Women and Children" by Yeh Kung-Shao; "Common Knowledge 
on Nutrition" by Chen Shu-Chi; "Common Knowledge of Nutrition" 
by the Chinese Academy of Medicine; "Food and Nutrition" by Huang 
Li; "Common Knowledge on Nutritional Hygiene" by Pang Wen- 
Chen; "Our Food and Nutrition" by Yu Ku; "Tables of Food Ingredi- 
ents" by Shung Yan Wei Sheng Yen Chiu Yuan; "People's Food and 



234 MEDICINE AND PUBLIC HEALTH 

Nutrition" by Chuang Yung-Chi; "Food Chemistry" by Lin Kung-Chi; 
"Food Hygiene in Food Preparation" by Fei Jun; and "Food Poison- 
ing" by Hou Hsiang-Chuan. As for journals, Ying Yang Hsueh Pao 
(Acta Nutrimenta Sinia) was started in 1956 but lasted for only three 
years. Nutritional literature in 85 different medical journals published 
before the cultural revolution was also scarce. Therefore, we believe 
that nutritional education through books and journals in China is 
grossly inadequate. 

Conclusion 

There is little doubt on the basis of scientific achievements, 
public health measures and reduction of illiteracy and ignorance, that 
the society of China has improved considerably in the last 22 years. 
With improvements in agricultural and industrial technology, trans- 
portation and nationwide planning, food shortages have been reduced. 
With the reported eradication of major infectious and parasitic diseases, 
the general health of all classes of people has probably improved. 
Severe malnutrition has supposedly disappeared. However, the task of 
feeding an expanding population of over 750 million people, who sub- 
sist on a limited amount of arable land, is not easy. The provision of 
good nutrition to pregnant women, in order to prepare a solid foun- 
dation for the proper mental and physical development of their off- 
spring, is the most important challenge to the leaders and nutritional 
workers in China. Despite the reported improvement in the nutritional 
status of the people, they are now faced with less apparent yet equally 
important nutritional problems. For example, control of goiter, which 
is so prevalent in the interior and mountainous areas of China, and 
studies on the interrelationship of nutrition and various neoplastic 
diseases, should now receive more attention. Efforts should be made to 
find out more precisely the nutritional status of Chinese people at 
various ages and from different geographic areas and to find the means 
of bringing their intake of various nutrients to optimal levels. 

We believe that a study of the nutritional problems in mainland 
China is a new challenge to workers in the United Sates. Our paper 
cannot provide adequate coverage of various subjects and our view- 
points undoubtedly are somewhat biased at times. We do hope this 
analysis of certain segments of great interest will illustrate the complex- 
ities and the importance of these problems. 

Progress in science cannot be achieved by one individual, one group, 
or even one nation. We hope that more material on nutritional re- 
search from the People's Republic of China will be made available to 
us in the near future. Our Chinese colleagues working in nutrition 



NUTRITION 235 

would probably like to share some of our thinking and eventually join 
the fight against hunger threatening the human race and against dis- 
eases which may be correctable or preventable by nutritional means. 



236 MEDICINE AND PUBLIC HEALTH 

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66. Haenszel, W. and Dawson, E. A.: "A note of mortality from cancer of the colon 
and rectum in the United States." Cancer 18:265, 1965. 

67. Wynder, E. L. and Hoffman, D.: Nutrition and Cancer in the Prevention of 
Cancer. (Ed. Raven, R. W. and Roe, R. J. C). Appleton Century-Crofts, New 
York, 1967 

68. Liang, P. C: "Studies of nasopharyngeal cancer in the Chinese." Chin. Med. J. 
83:373, 1964. 

69. MacDonald, R. A.: "Cirrhosis and primary carcinoma of the liver." New England 
J. Med. 255:1179, 1956. 

70. Hou, P. C: "The relationship between primary carcinoma of the liver and in- 
festation with clonorchis sinensis." /. Path. Bact. 72:239, 1956. 

71. Edmondson, H. A.: "Tumor of the liver and intrahepatic bile ducts." In: Atlas 



NUTRITION 239 

of Tumor Pathology, Armed Forces Institute of Pathology, Section VII, Fascicle 
25: p. 65, Washington, D.C., 1958. 

72. Copeland, D. H. and Salmon, W. D.: "The occurrence of neoplasms in the liver, 
lung and other tissues of rats as a result of prolonged choline deficiency." Am. 
J. Path. 22:1059, 1946. 

73. Sugiura, K.: "On the relation of diets to the development, prevention and treat- 
ment of cancer, with special reference to cancer of stomach and liver." /• Nutr. 
44:345, 1951. 

74. Hueper, W. C. and Conway, W. D.: Chemical Carcinogenesis and Cancer. Charles 
C. Thomas, 1964. 

75. Ishiwata, Y.: "Effect of difference of proteins (casein, gluten, zein) and supple 
ment of amino acids (lysine, tryptophan) on hepatic injuries induced by p- 
dimethylaminoazobenzene." Med. J. Osaka Univ. 18:347, 1968. 

76. Wogan, G. N.: "Naturally occurring carcinogens in foods." Progress Exp. Tumor 
Res. 11:134, 1969. 

77. Saito, M.: "Yellow rice toxins (detection of mycotoxins as carcinogenic hazards).'" 
Oncology 1970, V:176-178, (Ed. Clark, R. L., Cumley, R. W., McCay, J. E. and 
Copeland, M. C). Yearbook Medical Publishers, Chicago, 1971. 

78. Schoental, R.: "Liver disease and natural hepatotoxin." Bull. World Health 
Organization 29:823, 1963. 

79. Schoental, R.: "Recent developments in the field of pyrrolizidine alkaloids." 
Oncology 1970, V:203-213, (Ed. Clark, R. L., Cumley, R. W., McCay, J. E. and 
Copeland, M. C). Yearbook Medical Publishers, Chicago, 1971. 

80. Schoental, R.: "Aflatoxins." Ann. Rev. Pharmacol. 7:343, 1967. 

81. Butler, W. H. and Wigglesworth, J. S.: "The effects of aflatoxin Bl on the 
pregnant rat." Brit. J. Exper. Pathol. 47:242, 1966. 

82. Newberne, R. M., Harrington, D. H. and Wogna, G. N.: "Effects of cirrhosis and 
other insults on induction of liver tumor by aflatoxin in rats." Lab. Invest. 
15:962, 1966. 

83. Sun, S. C, Wei, R. D. and Schaeffer, B. T.: "The influence of postnecrotic cirrhosis 
on aflatoxin carcinogenesis in rats." Lab. Invest. 24:368, 1971. 

84. Guy, R. A. and Yeh, K. S.: "Peking diet." Chin. Med. J. 54:201, 1938. 

85. National Academy of Sciences: "Recommended Dietary Allowances." 7th Edition. 
National Academy of Science, 1968. 

86. Wu, H. and Wu, D. Y.: "Growth of rats on vegetarian diet." Chin. J. Physiol. 
2:173, 1928 

87. Buck, J. L.: Land Utilization in China. University of Chicago. Chicago, 1937. 

88. May, J. M.: The Ecology of Malnutrition in the Far and Near East, Hafnei 
Publishing Company, New York, 1961, pp. 9-52. 

89. Abbott, J. C: "Protein supplies and prospects: "The Problem in World Protein 
Sources." Advances in Chemistry, Ser. 57. Ed. Gould, R. F., American Chemical 
Society Publications, 1966. 

90. Leitch, I. and Godden, W.: "The efficiency of farm animals in the conversion 
of feedingstuffs to food for man." Imperial Bureau of Animal Nutrition, Tech- 
nical Communication No. 14 (1941), quoted by Woodham, A. A. in World Rexi. 
Nutr. Diet. 13:2-42, 1971. 

91. Huard, P. and Wong, M.: Chinese Medicine. McGraw Hill, 1968. 



INFECTIOUS AND PARASITIC DISEASES 



Kun-Yen Huang, M.D., Ph.D. 



INTRODUCTION 

In the past the Chinese frequently referred to themselves as 
the "weaklings of eastern Asia." While it may have also referred to 
the conditions of nonmedical domains of China in the past hundred 
years, the term may be appropriate for a country plagued for centuries 
by a wide variety of communicable diseases. The number of these dis- 
eases is so large that it is impossible to discuss all of them in this chap- 
ter. Hence ten of the diseases which in the author's judgment are of 
major importance on the Chinese mainland today were chosen. This 
selection inevitably had to be based on the author's own judgment, 
because medical publications have been nearly nil since the Cultural 
Revolution of 1966. The information contained herein was obtained 
mostly from medical articles which appeared before the Revolution, 
and partly from news and notes scattered among nonmedical publica- 
tions, which are sufficient only to provide the most sketchy of the 
current picture. 

The scope of the health problem as it existed in the early 1950's was 
unknown to the Chinese themselves. It was only gradually revealed 
after years of concentrated effort in nationwide surveys of existing dis- 
eases, their geographical distributions and the number of patients. At 
the same time, numerous institutions were established throughout the 
country, many of which were strategically located and specifically com- 
missioned to study a particular infectious disease in relation to its 
mode of transmission, the life cycles of its causative agents, and the bi- 
ology of its vectors, and to develop practicable control measures. 
Whether or not progress in these lines of work was in fact satisfactory, 
the government did set a target date for the "eradication of five most 
menacing parasitic diseases," i.e. schistosomiasis, malaria, filariasis, 

241 



242 MEDICINE AND PUBLIC HEALTH 

kala-azar, and ancylostomiasis, as part of its National Programme for 
Agricultural development in 1956. 

It is debatable whether these goals have ever been reached, yet evi- 
dence is abundant that many infectious diseases, parasitic or nonpara- 
sitic, have been brought under control. Cholera and smallpox have been 
literally wiped out. Sabin vaccine was produced domestically and used 
in a large scale vaccination program in 1960, resulting in a drastic re- 
duction in the incidence of poliomyelitis and the disappearance of the 
peak of seasonal incidence in the following years. 1 - 2 The control of 
measles seemed quite satisfactory with the production and clinical use 
of a live vaccine in 1 963-64. 3 - 4 Venereal diseases are probably the first 
infectious diseases brought under control as the byproduct of the 
change in the socioeconomic structure. Among the parasitic diseases, 
kala-azar is without doubt the most successfully combatted, although ev- 
idence indicates that the incidence rose after an initial drop in the late 
1950's. 5 It should be stressed that even the diseases which are still prev- 
alent in China, such as the ten chosen for discussion in this chapter, 
are decreasing in incidence. These ten diseases are tuberculosis, leprosy 
(Hansen's disease), trachoma, viral encephalitis, schistosomiasis, ma- 
laria, filariasis, clonorchiasis, paragonimiasis and ancylostomiasis. 

It is the intention of the author to provide a general picture of each 
infectious disease as it exists in China. Specific emphasis is placed on 
the distribution and prevalence of the disease, major achievements in 
research, both basic and clinical, and specific control measures. Infor- 
mation readily obtainable from other sources, such as symptomatology, 
unless deemed of particular interest, is not within the realm of this dis- 
cussion. It should be noted that two previous publications are available 
for additional information. 6 ' 7 

Tuberculosis 

Before 1949, the status of tuberculosis in China was quite 
obscure. Studies in a few major cities showed the prevalence rate to be 
3-9% of the population. Based on this figure, the minimum number 
of patients at this time can be estimated at 15,000,000. 8 The mor- 
tality rate per 100,000 for tuberculosis was 230 in 1949. A decade of 
antituberculosis campaigning brought about a decline in the prevalence 
rate to 1% in the cities, and the mortality rate to 46/100,000 in Peking 
in 1958, s still a considerably high rate compared to 6/100,000 in the 
U.S. in the same year. Further reduction in the mortality rate was 
seen through 1963. This disease, despite this remarkable drop in inci- 
dence, was still the number one killer in China in 1958. 9 

It is more prevalent in urban than in rural areas. Samples of tubercu- 
lin test surveys in 300,000 children 15 years of age or under carried out 



INFECTIOUS AND PARASITIC DISEASES 243 

from 1950 to 1956 in the Shanghai area show a steady increase in 
infection rate from infancy (Table 1). Similar rates of infection were 
reported from different localities throughout the country. 10 It is also 
clear from this table that the prevalence of infection, as manifestated by 
tuberculin test, did not decrease during the period from 1950 to 1956. 

Table 1. Prevalence of tuberculin positive reactions in children in the Shanghai 

area, 1950-1959* 

Percentage of positive reactions 
in different age groups 

Urban Rural 

(yr) (yr) 





1 


1-4 


5-9 


10-14 


15 


15 


1950 


5.9 


18.9 


53.2 


76.4 


82.9 


71.5 


1952 


5.3 


25.0 


57.3 


80.4 


87.0 


70.3 


1956 


5.3 


20.8 


47.1 


60.9 


91.8 


62.1 



•Adapted from Wei et al. 10 

In addition to pulmonary tuberculosis, tuberculous meningitis is 
quite common among children. Representative results from a series of 
studies in 1964 show that tuberculosis accounted for 5.8% of the total 
number of pediatric patients hospitalized. About one third of these 
cases were meningitis. 11 In fact it was urged that cases of aseptic menin- 
gitis be managed as tuberculous in nature until proved otherwise. The 
diagnosis of tuberculous meningitis was said to be facilitated by using 
the fluorescent Na diffusion rate test. 12 Tuberculous pleurisy and peri- 
tonitis on the other hand were common medical conditions encoun- 
tered in adults. The former accounted for 3.2%— 7.5% of hospitalized 
adult patients, and over half of them fell in the 16-25 year age group. 
The latter was responsible for 0.55% of all adult patients or 1.3% of 
those hospitalized in medicine, and was twice as common in the female 
than in the male. 13 Other conditions frequently encountered are bone, 
renal and miliary tuberculosis. Silicotuberculosis is probably of particu- 
lar importance. Silicosis is one of the most important occupational dis- 
eases in China. One study showed that 27% of the workers in a brick 
factory had silicosis; 30—40% of these cases were complicated by tuber- 
culosis. 14 The rate of complication with tuberculosis steadily increases 
as silicosis advances in severity, and it is believed that silicon oxide ex- 
erts an inhibitory effect on the body defenses, resulting in the activa- 
tion of old foci of tuberculosis. 

China was up-to-date in treatment of tuberculosis during the 1950's. 
The chemotherapeutics in use included streptomycin, isoniazid deriva- 
tives, p-aminosalicylate, viomycin, cycloserine and thiosemicarbazone. 8 
Among various types of tuberculosis, silicotuberculosis responded to 



244 MEDICINE AND PUBLIC HEALTH 

chemotherapy most poorly. 13 Artificial pneumothorax and pneumoperi- 
toneum were extensively used as auxiliary methods of treatment. Surgi- 
cal treatment included various kinds of collapse therapy and lobectomy 
or pneumonectomy, which was started in 1951. 15 Traditional medicinal 
herbs and acupuncture were widely applied, with the latter said to be 
especially effective for symptoms of neurofunctional origin, such as an- 
orexia and night sweating. 16 

A nationwide program of BCG inoculation was initiated in the mid- 
fifties. The immediate goal of the program was to vaccinate 1) all new- 
borns and 2) all healthy children under fifteen who were tuberculin 
negative. By 1964, it was claimed that more than 90% of newborn 
infants had been vaccinated. The logistic support, especially that of 
manpower, required by this enormous program was partly met in some 
localities by the short-course training of teachers of nurseries or elemen- 
tary schools in tuberculin testing and BCG inoculation. In 1960 there 
were six biological products laboratories producing PPD and BCG. In 
addition to the conventional BCG, lyophilized vaccine was experimen- 
tally produced in 1956, the stability of which was said to be highly 
satisfactory. 8 The drop in the incidence of tuberculosis in BCG- 
inoculated as compared to uninoculated children has been well 
documented. 8, "> 17 

Facilities for tuberculosis treatment, although increased significantly 
during the preceding years, were in the author's view still inadequate 
in 1960. There were 236 tuberculosis clinics, hospitals or sanatoria with 
a total of 36,000 beds. In addition, about 10% of the beds in general 
hospitals were reserved for tuberculosis patients. Of particular interest 
is a new type of nursery termed "Recuperation Nursery" which ap- 
peared in Tsintao, Shantung, in 1960, providing isolation, therapy and 
education for 1- to 6-year old urban children with active pulmonary tu- 
berculosis. The number of doctors directly involved in anti-tuberculosis 
campaigns were said to have increased from 100 before 1949 to 2,700 in 
1959. 8 

Education of the public in the mode of transmission and methods of 
control of the disease has been actively carried out. Routine roentgeno- 
logical examination, however, does not seem to be available for the ma- 
jority of the people. 

Leprosy (Hansen's disease) 

Leprosy (Hansen's disease) is distributed mostly in the 
tropics and subtropics. The disease has been recorded since ancient 
Chinese history, along with the cruelties to which leprosy patients have 
been subjected. It is estimated that about half of the 12,000,000 to 
20,000,000 world total of cases are in India and China. Roger and 



INFECTIOUS AND PARASITIC DISEASES 



245 



Muir estimated in 1946 that the total number of patients in China was 
1,000,000. 18 Accurate information is unavailable. Even the Chinese 
official figure given in 1951, 1,200,000 minimum, was accompanied 
by an acknowledgment that many cases could have been unregistered. 19 
According to Yii, 19 the inaccuracy of this figure is reflected in the 
classification of the patients. Representative data show that 47.7% of 
the cases belong to the tuberculoid type, with the remaining 52.3% 
lepromatous. These figures differ significantly from those generally ac- 
cepted by international leprosy investigators, i.e., 70% tuberculoid, 
20% lepromatous and 10% unclassified, suggesting failures in detect- 
ing tuberculoid leprosy cases. 

The distribution of the disease in China is also related to climate, 
rain and humidity, consistent with that observed in other parts of the 
world (Fig. 1). Not a single province or district is free of the disease. 
Among the 26 provinces and autonomous districts, Kwangtung, 
Kwangsi Chuang, Shantung, and Fukien have the highest incidence. The 
total number of patients in Kwangtung alone was estimated at 
600,000. 19 One out of a thousand people in Kwangsi Chuang, a region 
with a population of nearly 20,000,000, was a leprosy patient in the 
1950's. 19 In Shantung province, the prevalence rate was 4-12 per 10,000 
persons, depending on the region, and the total number was at least 
33,200. There were probably around 2,000 patients in each of the two 




Figure 1. Distribution of leprosy in China. Adapted from Yii. 1 



246 MEDICINE AND PUBLIC HEALTH 

large regions in the northwest, Sinkiang Uighur and Tsinghai, and 
only three cases were reported in Inner Mongolia, the area of lowest in- 
cidence. 19 It is more common in males than in females with a ratio of 
3.6:1, and the peak incidence is seen in the 20-39 year age group. 20 The 
onset of the disease is usually in young adulthood and the primary le- 
sion is most common in the lower extremities. 20 

One of the achievements claimed in the field of diagnosis of Hansen's 
disease is the papain-digestion-flotation method. The method essentially 
is the release and concentration of mycobacteria from involved tissues 
for better microscopic detection. It was said to have increased the posi- 
tive rate by a factor of at least six as compared to the conventional 
method of detection. 21 However it is not clear which staining procedure 
was followed in the actual detection of the microorganisms. A technique 
has also been described which used the viscera of leprosy patients who 
died in advanced stages as the source of lepromin. 22 This method was 
claimed to be much simpler and more productive than the conven- 
tional method which uses lepromatous lesions of skin as the source. 

Two major steps were taken toward the control of leprosy. One was 
the intensive campaign of the early 1950's to register patients in order 
to provide a clear picture of the extent of the disease. In areas of high 
endemicity general surveys were carried out, while in those of moder- 
ate endemicity, only sampling surveys were performed. A large number 
of personnel were given courses on the method of history taking and 
techniques of various examinations for this purpose. The other step 
taken was the education of the public on leprosy in order to bring pa- 
tients to seek medical assistance on their own initiative. The dramatic 
effect of this campaign was described by Yii. 19 Before 1949, leprosy pa- 
tients who came to seek treatment at a hospital in Shantung rarely 
came within a year of onset of the disease, and in fact in most the 
disease was too far advanced to give a satisfactory response to ther- 
apy. After a decade of public education, 20% of the patients seeking 
help came within a year of onset and some even came to request exami- 
nations merely because they had contact with leprosy patients. 

Despite these efforts, only modest progress was made by the end of the 
1950s. Only 151 clinics and control centers were established throughout 
the country. 23 Leprosaria, either expanded or newly established, totaled 
56. In addition, 703 so-called "leprosy villages," apparently a commune 
type lepra colony with dual functions of therapy and production, were 
set up. In this connection, it is interesting to note a study which led to 
a conclusion that a certain amount of physical labor could be beneficial 
to the course of leprosy. 24 By 1959, only about 60,000 patients had been 
admitted to these facilities and of these 6,000 had been discharged 
after satisfactory improvement. 23 Patients with tuberculoid leprosy are 



INFECTIOUS AND PARASITIC DISEASES 247 

generally handled at the out-patient clinic and those with lepromatous 
leprosy are isolated. Diaminodiphenylsulphone is the drug of choice. 
However, traditional medicinal herbs and acupuncture are widely used 
as supplementary therapeutic methods. The former are said to be more 
effective in restoring nerve functions than western medicine and the 
latter is said to be highly effective for neuralgia. 23 

It must be emphasized that the nationwide BCG vaccination pro- 
gram launched in the early 1950's had dual objectives of controlling tu- 
berculosis and leprosy. No follow-up report is available, however, and it 
is not known whether China has discarded this unpromising program. 

Trachoma 

Trachoma, although not a killer in its own right, is cer- 
tainly the most prevalent and disabling infectious disease in China. 
The estimated nationwide rate of infection was reported as 50% of 
the population in 1958, and depending on the locality, it could be 
as high as 90%. 25 On the basis of these figures, the total number of 
patients would be a staggering 300,000,000. The disease was distributed 
corner to corner throughout the country, including Tibet where 88% 
of the hospitalized patients with eye disease had either trachoma or 
its complications. The general pattern of distribution was that it was 
more prevalent in the north than in the south, in the west than in the 
east, among the poor than among the wealthy, in the countryside than 
in the city, in smaller cities than in larger cities. It was thus most 
prevalent in the northwest and least prevalent on the east coast. 26 
It has a peak incidence in the 11-30 year age group, 27 and is more 
common in females than in males. Representative studies show that 
trachoma is responsible for 45% of the impairment of vision and 
25-45% of blindness in China. 25, 27 The transmission of the disease is 
greatly facilitated by the habit of Chinese in sharing towels and other 
toilet articles in homes or in public. 

However, China has contributed to the understanding of trachoma as 
much as she has suffered from it. In 1957, T'ang et al. succeeded in cul- 
tivating the causative agent. 28 They were able to select the proper anti- 
biotics and concentrations to selectively suppress the growth of bacteria 
contaminating the conjunctival washings from which the agent was to 
be isolated. This success enabled them to study further the agent's 
growth characteristics in various cells, 29 and its physicochemical 
properties. 30 The impact of this breakthrough is quite obvious. In the 
ensuing years, different strains of this agent were isolated by investiga- 
tors all over the world, with T'ang's method, and subsequent studies of 
this agent led to a practical and efficient program of control. 

Attempts were also made to develop a vaccine. Both active and inacti- 



248 MEDICINE AND PUBLIC HEALTH 

vated vaccines were experimentally produced and tried in monkeys in 
1964. 31 Complement-fixing and hemagglutination inhibiting antibodies 
appeared in response to both vaccines, but a sustained effect was not ob- 
tained. The live vaccine was said to be significantly better than the in- 
activated vaccine, but results of further study are not available. 

Intensive public education was initiated in the 1950's. It was a direct 
attack on the chain of transmission with the slogans "one person one 
towel" and "running water for washing face" (face washing used to be 
done by using a basin which was shared by many persons). Besides, nu- 
merous mobile units and a network of antitrachoma stations were set 
up to examine and treat patients. These facilities were staffed by medi- 
cal professionals, paramedical personnel and medical aides in schools 
and factories who had been given short courses on anti trachoma cam- 
paigning. Two lines of work must have contributed considerably to the 
shaping of the mass control program. One is the simplification of the 
clinical classification into two stages from the conventional four stages, 
i.e., trachoma (Tr.) I, the progressive, and Tr.II, the regressive stage. 26 
The other is the revelation of the need of continuous drug therapy for 
a period of time after clinical cure, resulting from combined pathologi- 
cal and clinical investigation. 26 

Details of the current status of trachoma are not available, but evi- 
dence indicates that the disease is still not under proper control. 32 

Japanese B Encephalitis 

This disease is reported to be transmitted chiefly by Calex 
pipiens var. pollens, and Anopheles hyrcanus var. sinensis and is wide- 
spread throughout the country. The occurrence of epidemics is strictly 
seasonal, being closely related to the mosquito breeding cycle, and the 
peak incidence is seen in July and August. 33 In addition to their role 
as vectors, some claim that mosquitos transmit the virus vertically and 
therefore may be important reservoirs themselves. Various hoofed 
animals, especially pigs, are also natural reservoirs of the virus. In a 
series of studies conducted in the Peking area, 100% of the pigs were 
found to possess neutralizing antibody. 33 

There is usually a period in early summer with sporadic cases 
before an outbreak. Approximately one-third of the cases are under 10 
years of age, and one-half between 10 and 20 years of age. Subclinical in- 
fections are quite common. A large-scale serological survey shows 
that 67% of adults between 20 and 30 years of age and 80% of 
persons over 30 are immune to the disease. 33 In the Peking area, 20 to 
30% of the population have detectable complement-fixing antibodies 
after an epidemic season, indicating recent infections. 

The incubation period is 10-14 days. The disease has a gradual onset 



h 



INFECTIOUS AND PARASITIC DISEASES 249 

characterized by headache, fever, dizziness, vomiting, somnolence, neck 
stiffness and various neurological signs. 34 There are usually more severe 
cases and deaths during the first half of an epidemic than in the second 
half, and the most common cause of death is paralysis of the respiratory 
center. 33 The mortality rate was around 30% before 1949 but dropped / 
considerably in recent years. 34 Approximately 11% of the patients are 
discharged from the hospital with sequelae. 

The diagnosis can be made with little difficulty on a clinical basis 
and with serological tests. Measures of control described below for ma- 
laria are applicable also to Japanese B encephalitis. 

Schistosomiasis 

There is only one species of Schistosoma, S. japonicum, in 
China. The number of cases of schistosomiasis was estimated at 
10,000,000 in 1959. The disease was endemic in areas south of the 
Huai River and east of the Langtsang River, involving 3,000 square 
miles covering 12 provinces, 35 and was threatening the health of 
100,000,000 people. It was especially rampant along the great Yangtze 
River with the prevalence rate there reaching 60% in some villages. 
The only known intermediate host of schistosomes in China is 
Oncomelania hupensis. The spread of this snail corresponds with that 
of the disease and surveys have shown that wherever there is O. 
hupensis there are also human cases of schistosomiasis. Many domestic 
and wild animals have also been found naturally infected; the most 
important of these are cattle. 36, 37 

In the 1950's, at least forty-two schistosomiasis institutes were set up 
to extend a broad-spectrum research program. The areas of research in- 
terests ranged from the studies of modes of contracting the disease spe- 
cific to various types of farmland, and factors influencing the hatching 
of schistosome eggs in human and animal feces, to copulation, oviposi- 
tion, multiplication and hibernation of snails. 37 Results of these studies 
probably contributed significantly to the mapping of control measures 
of schistosomiasis. 

Most of the patients (62.9%) were in the 31-50 year age group. The 
incubation period was around 40 days. Acute phase schistosomiasis was 
characterized by fever and general symptoms of acute toxemia. 36 Leuko- 
cytosis, especially that of the eosinophilic cells which may account for 
88% of the total, was almost a constant finding. 36 In fact, absence of 
eosinophilia was indicative of graveness of the disease and poor prog- 
nosis. 37 One of the late manifestations of schistosomiasis was liver 
cirrhosis. Schistosomal hepatic cirrhosis differed pathologically from por- 
tal cirrhosis in that there was fibrosis in the periportal areas with nor- 
mal architecture of the hepatic lobules and without apparent or marked 



250 MEDICINE AND PUBLIC HEALTH 

nodular formation. 36 However, clinical manifestations of hepatic failure 
were uncommon, and liver cirrhosis or deterioration of hepatic func- 
tions could be halted by splenectomy and/or antischistosomal chemo- 
therapy. 36 Another important late manifestation of schistosome infections 
was endocrine disturbance, characterized by reduced tolerance to cold, 
loss of body and pubic hair, decreased libido and dwarfism. 36, 3S < 39 This 
was due primarily to the suppression of pituitary functions by toxic se- 
cretions of adult worms and miracidia within the ova or secondarily to 
the functional disturbances of the liver and intestine following re- 
peated infections during childhood. 37 The dwarfism was reversible upon 
appropriate antischistosomal treatment. 37, 38, 39 

During the acute stage, ectopic lesions occurred more frequently in 
the lung and brain than in any other organ. 40 Studies also showed 
higher incidence and an average of a 9.8-year earlier onset of colonic 
cancer among schistosomiasis patients than in the normal population. 41 
The duration of schistosomiasis before cancer varied from five to 20 
years. 41 

As is true for other major parasitic diseases, two methods were availa- 
ble for the diagnosis of schistosomiasis. Immunological diagnosis was 
made with the ova antigen prepared from infected rabbit liver. How- 
ever, the onset of a skin reaction was late after infection and persisted 
long after a successful treatment, rendering skin tests useless in the di- 
agnosis of acute cases and the assessment of the effects of the treatment. 
For early diagnosis, both the cercarial membrane reaction and circum- 
oval precipitating tests were said to be more practical. 37 A highly 
sensitive indirect hemagglutination test was also available but studies 
concerning its time of onset seem incomplete. Also in use was a comple- 
ment-fixation (CF) test which gave a somewhat lower (86.3%) positive 
rate. However, the combination of the CF test and skin test could in- 
crease the positive rate to nearly 100%. 43 The causative agent could be 
detected either by stool examination or rectal biopsy. For the former, 
best results were obtained by combining the sedimentation and hatch- 
ing techniques. The hatching time required was considerably shortened 
by increasing the incubation temperature to 40°C. 35 

Schistosomiasis is extremely hard to treat and complete cure is diffi- 
cult to attain. Drugs in use were mainly the antimonials. However, 
China has also been diligent in the search for new parasiticides. Per- 
haps the most important discovery in antischistosomal chemotherapy is 
the new drug furapromidine, also known by its code number F30066, 
which is an orally effective, nonantimonial therapeutic agent. 44 Chemi- 
cally, it is N-isopropyl-3-(5-nitro-2-furyl)-acrylamide (Fig. 2). 

It is said to be dramatically effective in acute schistosomiasis, al- 
though its effect in chronic cases is somewhat disappointing. 44 ' 45 Long 



INFECTIOUS AND PARASITIC DISEASES 251 



OoN CH = CHCONHCH(CH 3 ) 2 



Figure 2. Chemical structure of furapromidine. 

term use of this drug for 1.5-2.5 months at a daily dose of 50-80 mg/kg 
body weight given in four divided doses had an 81.4% egg conversion 
rate and immediate therapeutic results (probably judged by clinical 
improvement) were put at 83.8%. The drug is not without side effects, 
which disappear readily upon the termination of the medication. 45 
However, no information is available beyond the stage of clinical trail. 
A more conventional medical treatment with tartar emetic at a dose of 
12 mg/kg body weight with a maximum total dose of 700 mg in 2-3 
days was considerably more convenient in mass treatment than pre- 
viously practiced longer course treatment and was as effective and as 
safe. In addition to the medical approach, splenectomy is often used in 
cases with apparent hypersplenism and ascites. 44 ' 46 Traditional herb 
medicine and acupuncture are used for some aspects of symptomatic 
treatment. 37 ' 44 

Control measures can be summarized in three categories: a) Eradica- 
tion of the source of infection: patients and infected cattle were to be 
treated by the "three-day tartar emetic" method. 44 Parasite ova in night 
soil, an important fertilizer Chinese cannot afford to discard, were to be 
killed by storage with urine or the addition of chemicals. 37 b) Educa- 
tion of the public: the public was informed of the mode of transmission 
of schistosomiasis and of protection methods, including the use of repel- 
lents of cercaria on lower extremities. 35 c) Eradication of the intermedi- 
ate host: molluscacidal chemicals were produced to eliminate snails, 37 
streams were drained and various water conservancy projects were ini- 
tiated. 

The current status of schistosomiasis is quite disappointing. Abun- 
dant evidence indicates that, despite two decades of intensively fought 
antischistosomal campaigns, the disease has not been brought under 
control. Each year hundreds of thousands of people are mobilized to 
eliminate snails in endemic areas. According to recent information, the 
area of schistosomiasis endemicity has not diminished significantly 
from that of the early 1950's. 47 



252 MEDICINE AND PUBLIC HEALTH 

Malaria 

There were about 30,000,000 malaria patients in 1959. 36 
The distribution of malaria is shown in Table 2. All four types of 
malaria are present, of which falciparum and vivax are the two most 
prevalent. 37 In general, vivax malaria was widely spread throughout 
the endemic areas while falciparum was mainly concentrated in the 
south. 37 The disease plagued areas south more than those north of 
32°N, with an especially tight grip on areas south of 25°N, which 
include China's most well-known malarial breeding grounds such as 
Yunnan, Kweichow and Hainan. Several species of anopheline mosqui- 
toes responsible for the transmission of malaria have been identified 
and their distribution has been well studied (48, Table 2). Of par- 
ticular importance among these are Anopheles sinensis and A. lesteri 
which breed mainly in rice paddy fields and their seasonal role as 
vector corresponds well with the cycle of rice cultivation. Although 
malaria is endemic in all parts of China, outbreaks of epidemics do 
occur as the result of arrivals of nonimmune migrants to an area of 
endemicity or introduction of a species to an area in which it is not 
endemic. A typical outbreak of the latter type took place in 1953 in 
the Northeast when demobilized servicemen returning from Korea im- 
ported falciparum malaria, a type not indigenous in the area at the 
time. 37 

A nationwide antimalarial campaign, consisting of the treatment of 
patients and the control of vectors, was launched in 1956, 48 resulting in 
a steady drop in the incidence of malaria throughout the country. 
Today, China boasts domestic production of all antimalarial drugs, in- 
cluding chloroquine, primaquine, chloroguanide and others. The" ideal 
course of individual therapy of vivax malaria was said to be 15 mg of 
primaquine base for 14 consecutive days combined with a 0.6 gm base 
of chloroquine on the first day. The rate of relapse of malaria after such 
a course of treatment was reported to be inversely dependent on the pa- 
tient's age. 48 The relapse could be effectively checked by a second course 
of treatment, up to a total of 225 mg of primaquine. The duration of 
the interval between the two courses had little effect on the efficacy of 
the treatment. Shorter versions of these courses developed to suit mass 
treatment were: a) two courses of 180 mg of primaguine given in 8 
days, or b) two courses of 120 mg of primaquine given in 4 days. Both 
of these two mass therapies were carried out during the non transmis- 
sion seasons in order to prevent reinfection and to eliminate as many 
sources of infection as possible in one strike. This mass therapy pro- 
gram was especially hard pushed in areas where spraying operations 
were considered too costly. 

Benzene hexachloride (BHC) is mass produced in China and house 



INFECTIOUS AND PARASITIC DISEASES 



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254 MEDICINE AND PUBLIC HEALTH 

fumigation with this agent is done throughout the country during the 
active season to kill adult mosquitoes. In its powder form, BHC at an 
appropriate dosage is said also to be effective in eliminating larvae of 
A. sinensis and A. lesteri in rice fields. 48 However, the insecticidal effect 
of BHC does not last as long as that of dichlorodiphenyl-trichloro- 
ethane (DDT). 37 China has also had large scale programs of BHC or 
DDT spraying of households. However, because of fund shortages, the 
spray program had not been extended to all parts of the country by 
1965. 

Other sanitary measures were also taken to eliminate breeding places 
of mosquitoes. These measures included filling and drainage of ditches 
and other sources of stagnant water. Several suburban areas of Peking, 
formerly well-known as breeding grounds for mosquitoes, are said to be 
mosquito-free. 37 

Fiiariasis 

Filariasis is endemic in areas south of 37°5'N and involves 
at least 13 provinces. The number of patients was estimated at 
40,000,000. In areas of high endemicity, the prevalence rate could be 
over 30%, such as in Shantung, 37 or even over 50% such as in some 
parts of the deep south. A large number of cases are clinically asymp- 
tomatic until late in the course, and the proportion of such cases is 
especially high among children. 49 

Filariasis is caused by the nematode Wuchereria. Two species, W. 
bancrojti and W. malayi, have been identified in China. Both bancrof- 
tian and malayan filariasis are endemic in all provinces except Kwang- 
tung and Shantung in which only bancroftian filariasis occurs. As a rule, 
bancroftian filariasis is distributed mainly in the low-lying plains and 
malayan filariasis in the water-rich hilly districts of South China. The 
chief mosquito vectors of bancroftian filariasis are C. pipiens var. pal- 
lens, distributed north of 30°N, and C. pipiens var. jatigans, south of 
30°N. Malayan filariasis is chiefly transmitted by A. hyrcanus var sinen- 
sis, which infests mainly the area between 32°N and 25°N and also 
transmits malaria in the area. 48 In addition, Aedes togoi may serve as a 
secondary intermediate host for both species of Wuchereria in some 
areas along the sea coast. 

While acute symptoms offer little basis for distinguishing bancroftian 
for malayan filariasis, late manifestations do show considerable grounds 
for differentiation. Malayan filariasis is characterized by more common 
elephantiasis of the extremities, especially of the lower limbs, and rela- 
tively rare elephantiasis of the genital organs or chyluria. In bancrof- 
tian filariasis, on the other hand, 90% of the cases sooner or later show 
elephantiasis of genital organs as well as that of extremities, and chylu- 



INFECTIOUS AND PARASITIC DISEASES 255 

ria is quite common. 3R ' 57 It should be noted, however, that mixed infec- 
tion with both parasites does occur. The pathogenesis of lymphangitis 
in filariasis is manifold. It may be induced by adult filarial worms per 
se or their secretions, or secondary bacterial infections, for which Strep- 
tococcus is believed to play an important role. 50 Lymphangitis often fol- 
lows physical exertion and thus is more frequent in spring and summer. 
It is more severe in malayan than in bancroftian filariasis. 37 

Studies have also revealed that microfilarial periodicity is under the 
control of the activity of the vagus nerve, or in other words, is directly 
under the influence and control of the activity of the cerebral cortex. 51 

For immunodiagnosis, the antigen prepared from Dirofilaria imitis, 
the dog heart worm, is used for both skin and CF tests. Positive reac- 
tions in these cases were said to be 90% and 87% respectively. 37 These 
tests, which are clearly superior to blood examination in the diagnosis 
of filariasis, have not been used for mass survey because of logistic prob- 
lems in the mass production of the antigen. 

Hetrazan is the drug of choice. A therapeutic program suitable for 
mass treatment has been developed. 52 For the malayan filariasis, 1.0 or 
1.5 gm of hetrazan at night in quite effective. For bancroftian filariasis, 
which requires repeated medication, the suggested program is 0.5 gm 
twice a day for three days, with a total of 3 gm. The short course treat- 
ment, in its safety or efficacy in killing microfilariae and adult filaria 
worms, is said to be comparable to the longer 7-21 day conventional 
courses of treatment. 

The measures of filariasis control are similar to those of malaria con- 
trol and, therefore, will not be repeated. 

A few words for kala-azar at this point may not be entirely inappro- 
priate, since it was one of the original five parasitic diseases the Chinese 
strived to control. This disease, caused by Leishmania donovani, was 
distributed mainly in central China, especially the vast plains along the 
Yellow and Huai Rivers, with an estimated number of half a million 
cases. The intensive mass therapy campaign in the early 1950's, assisted 
by the intensive anti-sandfly program, led to a rapid decline in inci- 
dence. However, resurgence in the incidence was reported in the early 
I960's, 5 indicating a partial failure in attaining a long-standing sever- 
ance of the infection chain. 

Clonorchiasis 

Clonorchiasis, formerly known to be endemic only in some 
areas of Kwangtung and Kwangsi Chuang along the Chu Chiang 
(Pearl River), is widespread throughout the country, including 
Liaoning, Szechuan, Hopei and Shantung. 37 - 53 The prevalence rate 



256 MEDICINE AND PUBLIC HEALTH 

varies from village to village, and could be as high as 40% in some 
highly endemic areas. 

This disease is caused by Clonorchis sinensis (liver fluke), the only 
species known to exist in China. Man is infected by eating raw or 
partly cooked parasitized fresh water-fish. An interesting feature in the 
epidemiology of this disease is the relationship of the degree of en- 
demicity and age distribution to the custom of eating fish. T'ang et al. 
pointed out 54 that the peak of age incidence of the disease is in the 
middle-age adult group and that the disease is highly endemic in areas, 
such as Kwangtung, where people have the custom of eating raw fish. In 
the endemic areas which were discovered after 1949, where the custom 
of eating raw fish is not prevalent, the disease is lower in endemicity 
and its peak incidence is seen in children under 15 years of age. For 
example, in Fukein, which belongs to the newly discovered endemic 
areas, 80% of the cases are seen in the 1-15 year age group. 54 According 
to statistical data obtained in Hong Kong, which are also believed to 
be applicable to Kwangtung, 40% of the autopsy cases over 40 years of 
age have clonorchiasis and the mean age incidence of the disease is 45. 55 

A variety of snails serve as the first intermediate hosts of the parasite 
including those of genera Parajossaralus and Bithynia. The secondary 
intermediate host includes various kinds of freshwater fish, of which 
grass carp is the most important in Kwangtung. Man is infected when 
fish containing encysted metacercaria is ingested. Besides man, dogs and 
cats also are important natural reservoirs of Clonorchis. 

The disease is confined to the hepatobiliary system. It is character- 
ized by a gradual onset of anorexia, abdominal pain located in the 
right upper quadrant simulating that of choledochitis or acute cholecys- 
titis, abdominal distension, loss of weight, diarrhea and hepatomegaly. 
The blood picture usually shows marked eosinophilia. 56 

A study conducted in Kwangtung shows that 39% of hospitalized 
cases of cholecystitis were due to clonorchiasis. 56 These cases often re- 
quire surgical intervention at some stage of the disease. For example, in 
the same study, it was shown that 4.8% of all the hospitalized surgical 
patients were cholecystitis cases and in about 50% of them the ailment 
was due to clonorchiasis. Late stage clonorchiasis often leads to liver 
cirrhosis. A higher incidence of hepatoma among clonorchiasis patients 
has also been reported. 56 

Diagnosis of the disease by stool examination is simple in technique 
but mild cases often escape detection. The stool examination is re- 
peated at least three times in the same individual in mass surveys. An 
intradermal test with antigen prepared from adult Clonorchis was in- 
troduced by Chung et al. 57 and has been widely used. However, highly 
diluted antigen must be used to avoid cross reaction with Schistosoma 
and Paragonimus. 56 



INFECTIOUS AND PARASITIC DISEASES 257 

Chemotherapy of clonorchiasis is unsatisfactory, especially in chronic 
cases. In fact, drugs may only depress the reproductive system of the 
flukes without killing them. Relapses are commonly seen in treated 
cases. 37 Chloroquine was considered to be the best chemotherapeutic 
agent available in the early 1960's but the long course and large dose 
required rendered it impractical in mass treatment. 37 Oral hexachloro- 
phene, given at a dose of 20 mg/kg/day for three consecutive days, was 
reported to be highly effective against the parasite. Parasite ova disap- 
peared from the stool in 41% of the cases in two to three weeks along 
with expulsion of a large number of adult worms. In this particular 
study, relapse or reappearance of ova in the stool did not occur during 
the four-month period of follow-up. 58 Hexachloroparaxylol was also 
used but the results seemed less satisfactory than with hexachlorophene. 
Untoward reactions of these drugs have been well described, 56, 58 and it 
is not clear whether these drugs have ever been used in a large scale 
therapeutic program. 

Some of the steps taken for the control of clonorchiasis, including 
elimination of snails and disposition of night soil, are part of the gen- 
eral campaign to eliminate four pests (snail, mosquito, rat and spar- 
row) and five major parasitic diseases. The Chinese authorities now 
insist on the composting of human manure before it is used in fish 
ponds. Hazards in eating uncooked fish and the need of improvements 
in environmental sanitation were stressed in public education. These 
multifaceted efforts have probably to some extent broken the cycle of 
\and reduced the incidence of clonorchiasis. This conclusion, given by 
Gibson and Sun, was based on their observation of the sharp drop in 
the presence of metacercarial cysts of Clonorchis in recent fish exports 
from Kwangtung to Hong Kong. 55 

Paragonimiasis 

Paragonimiasis, caused by the lung fluke Paragonimus, is 
wide spread in at least fifteen provinces. The areas in which it has 
been reported extends from Liaoning in the Northeast to far south 
in Yunnan, with central China as the most highly endemic area, where 
the prevalence rate was 67% 59 in some villages. In the Northeast 
where paragonimiasis was discovered in 1955, 47% of the population in 
the Sung-hua Chiang area are infected. More than half of the cases 
are in the 11-15 year age group. 59 

Chinese scientists claim that two species of Paragonimus, P. wesler- 
rnani and P. Skrjabini are existent, and the diseases caused by these two 
parasites are said to be distinguishable on clinical grounds. In general, 
P. skrjabini is limited to Szechuan, Kiangsi, Yunnan and some parts of 
Kwangtung, while P. westermani is distributed in the remainder of the 
endemic areas. 59 - 60 - 61 Besides man, both domestic and wild animals are 



258 MEDICINE AND PUBLIC HEALTH 

important natural reservoirs. The first intermediate hosts are opercu- 
lated snails of various genera, and the second intermediate hosts in- 
clude a wide variety of fresh-water crabs, such as cray-fish. 37 

The incubation period is three to six days and the onset usually in- 
sidious. 59 The most common symptoms of the disease caused by P. wes- 
termani are productive cough, hemoptysis and chest pain. However, the 
patient's sense of well-being is usually not significantly impaired. These 
symptoms may be preceded by a certain period of abdominal pain and 
distension, diarrhea or pus and blood in the stool. Marked eosinophilia 
is a constant finding. In P. skrjabini infection, pulmonary symptoms 
are less severe and hemoptysis less frequent but eosinophilia and pul- 
monary effusion are more marked than in P. westermani infection. 
Migratory subcutaneous swellings caused by travelling worms are more 
common in P. skrjabini than in P. westermani infection. 60 

According to one study, Paragonimus involved the brain in 11% of 
the cases. 00 The clinical manifestations of the brain involvement are 
headache, epileptic seizures and other symptoms simulating meningitis 
or brain tumor. The route of travel of adolescercaria of Paragonimus 
from the lung to the brain has been studied in detail. 62 

Pathologically, P. skrjabini cysts, unlike those of P. westermani, are 
completely devoid of parasite ova. In fact ova of P. skrjabini are diffi- 
cult to find in sputum, pleural effusion, cerebrospinal fluid and subcu- 
taneous swellings. 60 However, cysts of P. skrjabini are more numerous 
than those of P. westermani in the pathway of Paragonimus adolescer- 
caria from abdominal to the pleural cavity, i.e., the abdominal surface 
of the diaphragm and the anterior border and the subdiaphragmatic 
surface of the liver. 

The diagnosis of pulmonary paragonimiasis is not a simple matter in 
a country with highly prevalent pulmonary tuberculosis. As a result 
paragonimiasis patients are often mistaken for and treated as tubercu- 
losis patients. Although careful roentgenological examinations in skill- 
ful hands may differentiate paragonimiasis from tuberculosis, 63 the di- 
agnosis of paragonimiasis relies primarily on the demonstration of 
parasite ova in the sputum or an intradermal or CF test with antigen 
prepared from adult worms obtained in artificially infected animals. 
Both of these immunological tests are said to be highly specific with 
positive rates reaching nearly 100%. The skin test, therefore, was used 
in the mass survey of paragonimiasis. 64 The same antigen is also used 
in the detection of antibody in the cerebrospinal fluid of patients with 
central nervous system involvement. The positive rate was reported to 
be 83.3%. Besides, abnormal electroencephalographic findings of brain 
paragonimiasis may help in establishing the diagnosis. 

The drug of choice for paragonimiasis, bithional [2,2'-thiobes 4,6- 
dichlorophenol) ], is produced in China. 44, 60 A so-called 20-day-course 



INFECTIOUS AND PARASITIC DISEASES 259 

treatment, with 1 gm of this drug given orally in three divided doses a 
day every other day totalling 30 gm, is a standard program. The relapse 
rates after this treatment were said to be 2.8% in pulmonary and 4.4% 
in cerebral paragonimiasis. For patients with cerebral paragonimiasis 
involvement, a combination of bithional and emetine is desirable. 60 

The control measures for paragonimiasis are similar to those for 
clonorchiasis and therefore will not be repeated. 

Ancylostomiasis 

Ancylostomiasis, or hookworm disease, is a highly endemic 
parasitic disease involving at least 15 provinces. Areas of highest 
endemicity are those along the Chu Chiang, the Yangtze River and the 
coast. The incidence is highest among young adults. Even among chil- 
dren, the prevalence rate may reach 50% in areas of high endemicity. 
It is generally more prevalent in the south than in the north. The 
only regions spared of the disease are the northwestern parts and 
Inner Mongolia. 37 

Two hookworms, Ancylostoma duodenale and Necator americanus, 
have been identified. Patients in most areas are infected with both para- 
sites. In the south, however, the disease is predominantly due to N. 
americanus. The total number of patients was estimated at 100,000,000 
in 1959. 37 

Clinical investigations have revealed that besides creeping eruptions, 
pulmonary symptoms consisting chiefly of dry cough but with occa- 
sional blood-streaked sputum containing larvae are quite common in 
the early stage of the disease. Chronic cases are characterized by ane- 
mia, malnutrition and loss of weight. 

Results of investigations show that hookworm ova develop and hatch 
into larvae only in soil with suitable temperature. 37 Thus, unlike past 
belief, rice fields play an insignificant role in the transmission of hook- 
worm disease. The disease is acquired mainly through the cultivation 
of dry land crops, especially those which need frequent fertilization, 
such as sweet potatoes, corn, tobacco, vegetables, and mulberry and 
fruit trees. Therefore, the infection season is closely linked to the culti- 
vation cycle of various crops. 37 

In addition to methods of detection of parasite ova in the stool simi- 
lar to those applied to schistosomiasis, an intradermal test for ancylos- 
tomiasis apparently proved to be highly suitable for mass survey. 37 ' 66 
The test, which employs antigen prepared from adult hookworm, is 
said to be highly specific and is positive in 99.5% of hookworm cases. 

Bephenium hydroxylresorcinol was mass-produced in 1960 44 and 
widely used as the therapeutic agent. A new drug, the bephenium salt 
of gallic acid, developed in 1963, was said to be quite satisfactory in the 
preliminary trial, 44 but the result of large scale field trials are not 



260 MEDICINE AND PUBLIC HEALTH 

available. The search for better therapeutics for ancylostomiasis was 
quite active in the early 1960's. 44 

Readers are referred to the section on schistosomiasis for the control 
measures for ancylostomiasis. 

Conclusion 

Parasitic diseases, as is clear from this discussion, constitute 
the major threat to the health of Chinese people. According to the 
data compiled in 1959, the total entries of parasitic diseases was an 
incredible 280,000,000. 36 This means that one out of every two to 
three persons dwelling in China at the time might have had a parasitic 
disease, although this was not necessarily so because mixed infection 
with more than one parasitic agent was a common occurrence. On the 
other hand, the credibility of Chinese statistical data has always been 
questioned on the ground that scientific procedures of data collection 
are not rigidly followed. Such a deficiency often leads to an under- 
estimation rather than an overestimation and thus the actual number 
of parasitic disease entries may have been well over 280,000,000. There- 
fore, it seems logical that Chinese authorities have directed more con- 
certed efforts to the so-called five most menacing parasitic diseases than 
to tuberculosis, ranked number one as the cause of death, or to 
trachoma, ranked number one in prevalence. 

Despite failures in some aspects of health work and relatively slow 
progress in the control of infectious diseases, the prospect for greater 
success in the near future could be quite good. The greatest guarantee 
for this success is seen in the ability of Chinese medical professionals to 
keep themselves up to date in the medical sciences and the striking suc- 
cess in the improvement of environmental sanitation, which have 
caught even the most experienced eyes of recent visitors to China. 67 It 
is, in fact, remarkable that such a high degree of success could have 
been achieved amid the chaos of the postwar period involving a quarter 
of the world's population. There is no doubt that China has the will 
and perhaps the capacity to bring these devastating communicable dis- 
eases under control, and rescind the title of "the weakling of eastern 
Asia." 



INFECTIOUS AND PARASITIC DISEASES 261 

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Ophthalmol. 9:334-336, June 1959. 

27. Huang, S. H., Cheng, C, and Fu, H.: "A report on trachoma survey." Chin. J. 
Ophthalmol. 8:60, January 1958. 

28. Tang, F. F., Chang, H. L., Huang, Y. T., and Wang, K. C: "Studies on the eti- 
ology of trachoma with special reference to isolation of the virus in chick embryo." 
Chin. Med. J. 75:429-446, June 1957. 

29. Li, T. H., Shen, M. C, Chou, Y. P., Kuo, Y. H., Chen, F. Y., Lin, F. C, Kuo, P. K., 
and Wu, H. C: "Chick embryo entodermal cell tissue culture medium for isolation 
and serial passage of trachoma agents." Chin. Med. J. 82:731-739, November 1963. 

30. Chang, H. L., and Chen, H. Y.: "Studies on trachoma virus with various physical 
and chemical agents for prophylaxis." Chin. Med. J. 81:779-783, December 1962. 

31. Chang, H. L., Chen, H. Y., and Wang, K. C: "Experimental studies on trachoma 
vaccine in monkey." Chin. Med. J. 83:755-762, November 1964. 

32'. Prevention and treatment of common ophthalmic diseases. Ed. by Ophthalmol. 
Dept. of Hsin-hua Hospital, Shanghai Municipal Publication Revolutionary 
Group, Shanghai, August 1970. 

33. "Progress in internal medicine in New China," an editorial. Chin. Med. J. 79:219- 
252, September 1959. 

34. Huang, C: "Diagnosis and treatment of Japanese B encephalitis." Chin. J. Fed. 
15:117-119, February 1966. 

35. Wei, W. P.: "Battle against schistosomiasis." Chin. Med. J. 80:299-306, April 1961. 

36. Hou, T. C, Chung, H. L., Ho, L. Y., and Weng, H. C: "Achievements in the fight 
against parasitic diseases in New China." Chin. Med. J. 79:493-520, December 
1959. 

37. Feng, L. C, Mao, S. P., and Liu, E. H.: "Research on parasitic diseases in New 
China." Chin. Med. J. 80:1-20, January 1960. 

38. Chu, H. H., Chang, M. F., Wang, F., Hsieh, S. C, and Lin, C. C: "Observations 
on endocrine disturbances in patients with late schistosomiasis japonica." Chin. 
Med. J. 82:374-378, June 1963. 

39. Hsiieh, C. H., and Wu, Y. H.: "Endocrine disturbances in late schistosomiasis, a 
clinical study of 17 cases." Chin. Med. J. 82:519-527. August 1963. 

40. Chou, H. C, Hsu, C. F., Huang, P. M., Wei, M. H., Chou, H. L., and Tsai, 
W. M.: "Clinical manifestation and management of 138 severe cases of acute 
schistosomiasis." Chin. J. Ped. 15:19-22, January 1966. 

41. Chen, M. C, Hu, J. C, Chang, P. Y., Chung, C. Y., Tsao, P. F., Chang, S. H.. 
Wang, F. P., Chen, T. L., and Chou, S. C: "Pathogenesis of carcinoma of the colon 
and rectum in schistosomiasis japonicum. A study of 90 cases." Chin. Med. J. 
84:513-525, August 1965. 

42. Huang, T. W., Ti, T. F., Cha, C. 1... and Hu, C. C: "Indirect hemagglutination 
test (slide method) in the diagnosis of schistosomiasis japonicum." Chin. Med. J. 
85:96-104, February 1966. 



INFECTIOUS AND PARASITIC DISEASES 



263 



43. Wang, T. H., and Cheng, C. L.: "Preliminary report on the clinical value of the 
intradermal and complement fixation tests in the diagnosis of schistosomiasis." 
Chin. J. Parasit. Inject. Dis. 2:32-37, February 1959. 

44. "Achievements in medicine in the past five years in our country," an editorial. 
Chin. J. Int. Med. 12:905-917, October 1964. 

45. Chou, H. C Huang, F. M., Chou, H. L., and Wei, M. H.: "Clinical evaluation of 
F30066 in long-course treatment of schistosomiasis japonica." Chin. Med. J. 84: 
591-598, September 1965. 

46. Chou, H. C, Hsii, C. F., Tsu, S., Tsai, W. M., Chou, H. L., and Chang, C. H.: 
"Clinical analysis and follow up observation in 97 cases of schistosomal Cirrhosis 
with ascites." Chin. J. Int. Med. 13:324-326, April 1965. 

47. New York Times, March 15, 1970. 

48. Ho, C: "Studies on malaria in New China." Chin. Med. J. 84:491-497, August 
1965. 

49. Liu, H. Y.: "Progress in the prevention of filariasis in children in New China." 
Chin. J. Ped. 10:429-431, May 1959. 

50. Liu, Y. K.. Hsieh, S. C, and Tai, T. Y.: "The role of steptococcal infections in 
filariasis." Chin. Med. J. 83:17-22, January 1964. 

51. Wang, C. F., Lin, C. L., and Chen, W. H.: "The mechanism of microfilarial 
periodicity." Chin. Med. J. 77:129-135, August 1958. 

52. Li, C. H., Chin, L. C, and Chiang, C. H.: "Observations on the short-course and 
large dose treatment of malavan filariasis." Chin. J. Med. 49:170-175, May 1963. 

53. Ma, H. C, Yeh, Y. C, Feng, Y. S., Tsao, C. C, and Li, C. C: "Clonorchiasis in a 
new endemic area in east Shantung province. A preliminary report on the use of 
the intradermal test in an epidemiologic survey." Chin. Med. J. 83:812?818. De- 
cember 1964. 

54. T'ang, C. C, Lin, Y. K., Wang, P. C, Chen, P. H., T'ang, C. T., Chen, C. F., and 
Chen, S. H.: "Clonorchiasis in south Fukien with special reference to the discovery 
of cray fishes as second intermediate host." Chin. Med. J. 82:545-562, September 
1963. 

55. Marcial-Rojas, R. A., editor: Pathology of Protozoal and Helminthic Diseases with 
Clinical Correlation. Williams & Wilkins Company, Baltimore, Md., 1971, p. 564. 

56. Weng, H. C, Chung, H. L., Ho, L. Y., and Hou, C. C: "Studies on clonorchiasis 
sinensis in past ten years." Chin. Med. J. 80:441-445, May 1960. 

57. Chung, H. L., Weng, H. C, and Hou, T. C: "Immunodiagnosis and chemotherapy 
of clonorchiasis sinensis with special reference to efficacy of chloroquine, includ- 
ing a note on negative efforts of oxychloroquine." Chin, Med. /., 73:1-14. 
January 1955. 

58. Liu. J., Wang, C. N., Yii, J. H., Wang, M. N., Chang, C. F., and Cheng, S.: "Hex 
achlorophene in the treatment of clonorchiasis sinensis." Chin. Med. J. 82:702-711, 
November 1963. 

59. Chen, C. H., and Yuan, C. W.: "Progress in the research of paragonimiasis in New 
China." Chin. J. Ped. 10:474-476, June 1959. 

60. Wang, C. N., Liu, J., Chang, T. F., and Miao, H. C: "The clinical manisfestations 
and bithional therapy of paragonimiasis in Szechuan province." Chin. Med. /. 
83:163-170, March 1964. 

61. Chen, H. T.: "The identity of Paragoninins schechuanensis, Chung and Ts'ao and 
P. westermani (Szechuan variety) ." Chin. Med. J. 82:456-462, August 1963. 

62. Lin, C. K., and Lei, T. M.: "The pathologic anatomy of paragonimiasis." Chin. 
Med. J. 82:650-658, October 1963. 



264 MEDICINE AND PUBLIC HEALTH 

63. Wang, S. H., and Liu, K. N.: "Roentgenology in diagnosis of paragonimiasis.'' 
Chin. Med. J. 79:446-455, November 1959. 

64. Chung, H. L., Hou, C. C, Li, Y. F., and Tsao, C. C: "Further study on the intra- 
dermal test of paragonimiasis (an observation of 710 cases) ." Nat. Med. J. Chin. 
43:109-110, February 1957. 

65. Feng, Y. K., Wang, S. C, Mo, P. S., and Chang, H. L.: "Electroencephalographic 
findings in paragonimiasis," Chin. Med. J. 82:418-422, July 1963. 

66. Lu, P. Y., and Sun, H. P.: "Preliminary reports on an intradermal test of ancylos- 
tomiasis." Chin. J. Parasit. Dis. 1:264-268, September 1958. 

67. Dimond, G.: "Medical education and care in People's Republic of China." JAMA 
218:1552-1557, Dec. 6, 1971. 



CANCER RESEARCH ORGANIZATION AND 
PREVENTIVE PROGRAMS 



Haitung King, Ph.D. 



INTRODUCTION 

Since the founding of the People's Republic of China in 
1949, Western investigators have shown a keen interest in its public 
health activities. Popular and scholarly reports on the health revolu- 
tion in New China have appeared under such provocative captions as 
"Barefoot Doctors,'' "Great Leap Forward", 1 and "From Village to 
Commune". 2 The revolutionized medical services in the People's Re- 
public have been documented by a British surgeon in a book-length 
account, 3 based on the author's first hand experience. The book reflects 
his familiarity with the grass-roots operation of the services and the 
underlying political ideologies. Other aspects of health and medicine 
in the new regime, ranging from the barely noted subject of medical 
education and manpower ' to the much publicized practice of acupunc- 
ture, 5 have been described in these publications. 

Certain sectors of the health revolution in New China have been 
slighted. In Western circles, little attention has been directed to the 
achievements in organizing research and preventive programs in 
chronic diseases. Such a tabula rasa has been unfortunate, particularly 
in consideration of an increasing life expectancy in New China. The 
present paper is directed forward filling that gap, although its scope of 
inquiry is confined to a single but significant group of chronic morbid 
conditions, namely, malignant neoplasms. 

Organization of Cancer Research 

Since China entered the area of modern medicine in the 
early 1900's, cancer has continued to command strong interest among 

265 



266 MEDICINE AND PUBLIC HEALTH 

members of Chinese medical professionals. A series of papers on 
"Cancer in China" was delivered before the 19th Biennial Conference 
of the Chinese Medical Association in 1929. During this conference 
a resolution was made urging the League of Nations to consider form- 
ing a special commission. The purpose of such a commission was to 
investigate the regional distribution of cancer in China and neighbor- 
ing countries and its possible relation to racial differences in diets and 
ways of living. 6 The first Tumor Clinic was initiated in 1932 at the 
Peking Union Medical College. 7 Three years later, the Association con- 
ducted a survey of tumor incidence (benign and malignant) in hos- 
pital patients. 8 

With the founding of the People's Republic, the concern with ma- 
lignant neoplasms has greatly intensified. An account of some such ac- 
tivities is given below. 

General Organization and Activities. The importance of cancer re- 
search was clearly indicated in the national 12-year plan for scientific 
development proclaimed in 1956. The proliferation of agencies devoted 
to cancer studies showed the impact of the program (Appendix A). In 
experimental tumor research alone, there were about 24 agencies en- 
gaging in such activities until 1959, notably the Tumor Institute, the 
Research Institute of Experimental Biology, the Research Institute of 
Pharmacology, and the Research Institute of Experimental Medicine, 
all in the Academy of Medical Sciences. The Research Institute of Ex- 
perimental Medicine consists of six tumor research units: Tumor 
Etiology, Tumor Therapy, Tumor Immunology, Tumor Metabolism, 
Human Tumor Heterologous Transplantation, and Human Tumor 
Tissue Culture. Research in epidemiology of cancer is mainly con- 
ducted by the various medical colleges throughout the country. 

Since 1958 several research institutes in the Academy have collabo- 
rated closely in cancer investigation. In the same year a special chorio- 
carcinoma study section began in the Academy. A Cancer Research 
Unit at the Szechuan Medical College was founded in 1958, followed by 
the organization of the Academy's Committee for Cancer Research, and 
similar committees in Shanghai, Tianjin, Chengtu, and other cities. A 
National Cancer Conference was held in Tianjin in 1959 and the "Col- 
lected Papers" of the Conference were published the next year. In- 
cluded in these papers was a statistical study of about 277,000 surgical 
specimens of tumors from 36 medical colleges in 26 districts in China. 1 ' 
About this time, a conference was held on esophageal malignancy for 
four provinces and one city, followed by two conferences on cancer of 
the nasopharynx in 1960 and 1961. 

In recognition of the Soviet accomplishments in the areas of cancer 
research and anti-cancer organization, a team of Chinese scientists was 



CANCER RESEARCH 267 

sent to the U.S.S.R. in 1960 to learn from its experiences. 10 Two years 
later the Chinese cancer scientists submitted 33 papers to the Eighth In- 
ternational Cancer Congress covering such areas as carcinogenesis, epi- 
demiologic and pathologic aspects of cancer, the biology of cancerous 
cells, and the new drugs in experimental use against cancer. 11 In 1964, 
104 papers were delivered before a cancer conference of Chung Shan 
Medical College following the ceremonial dedication of Huanan 
(South China) Cancer Hospital in Canton. 12 A translated edition of 
Treatment of Cancer and Allied Diseases: Tumors of the Head and 
Neck by Pack and Ariel 13 appeared in 1964, 14 six years after the publi- 
cation of the original work in Britain. The second National Cancer 
Conference was held in 1965 and the third one in 1969. A second 
conference on esophageal cancer at the provincial level was held in 1972 
in Lin County, Honan. 

We have no full knowledge of the formal organization of clinical can- 
cer research. However, there are a 300 bed Tumor Institute in the 
Academy of Medical Sciences and the Tumor Hospital at the Shanghai 
First Medical College, established about 1950. The Huanan (South 
China) Cancer Hospital, dedicated in 1964, has 140 beds and consists 
of formal Departments of Radiology, Internal Medicine, Gynecology, 
Chest and Abdomen, and Head and Neck. Two other tumor hospitals 
were established in Hangchow (Chekiang province) and Taiwan (Shansi 
province). The Tumor Department at Tianjin Hospital has the status 
of a hospital. 

Epidemiologic and Morphologic Studies. A detailed review of epi- 
demiologic aspects of cancer will be published separately. 15 Some 
morphologically relevant information is presented below. 

The histologic classification of some 18,000 microscopically examined 
specimens (mainly those of the former Peking Union Medical College) 
is presented in Table 1. One comment seems in order, i.e., an apparently 
low frequency of Hodgkin's disease. Special mention is made of a study 
based on 1,979 necropsies from 38 medical colleges throughout the 
country during the period 1950-1957. 17 Included here is information on 
the geographic distribution of histologic types for several primary sites, 



Table 1. Percentage Distribution of Carcinomas by Histologic Type and Sex, Peking 
Union Medical College, 1917-1957 

Sex 
Histologic Type Males Females Unknown 

All Malignancies 7,446 9,966 846 

Carcinoma 5,137 8,151 491 

(69.0) (81.8) (58.0) 



268 



MEDICINE AND PUBLIC HEALTH 



Table 1. (continued) 









Sex 


Histologic Type 


Males 


Females 


Unknown 


Squamous cell carcinoma 


53.9 


64.1 


45.2 


Transitional cell carcinoma 


3.1 


0.7 


4.7 


Basal cell epithelioma 


2.4 


0.9 


3.9 


Carcinoma of simplex 


15.8 


18.0 


24.6 


Adenocarcinoma 


17.1 


12.8 


16.9 


Papillary adenocarcinoma 


1.0 


2.1 


0.8 


Lymphoepithelioma 


4.7 


0.6 


3.7 


Embryonal carcinoma 


2.0 


0.2 


0.2 


Carcinoma in situ 


+ 


0.6 




Sarcoma 


598 


309 


101 




(8.0) 


(3.1) 


(11.9) 


Fibrosarcoma 


57.5 


61.2 


70.3 


Synoviosarcoma 


5.0 


2.3 


5.9 


Myxosarcoma 


4.7 


3.9 


8.9 


Chondrosarcoma 


5.0 


3.2 


1.0 


Osteosarcoma 


12.7 


9.7 


12.9 


Neurofibrosarcoma 


15.1 


19.7 


1.0 


Lymphoma 


525 


167 


37 




(7.1) 


(1.7) 


(4.4) 


Lymphosarcoma 


54.5 


47.9 


59.5 


Reticulum cell sarcoma 


32.4 


41.3 


27.0 


Hodgkin's disease 


13.1 


10.8 


13.5 


Other malignancies 


1,188 


1,339 


217 




(15.9) 


(13.4) 


(25.7) 


Giant cell sarcoma 


7.3 


3.7 


6.0 


Gliosarcoma 


2.1 


0.5 


4.1 


Neuroblastoma 


1.3 


1.0 


0.5 


Melanotic melanoma 


7.3 


5.4 


8.8 


Ameloblastoma 


6.7 


1.6 


2.3 


Mixed tumors, salivary gland type 26.9 


17.8 


22.1 


Wilm's tumor 


0.4 


0.4 


0.5 


Teratoma 


4.8 


28.6 


4.6 


Chorioepithelioma 


0.1 


11.7 


0.5 


Other 


16.7 


15.6 


26.7 


Unspecified 


26.4 


13.7 


24.0 



Figures in parentheses indicate percentage of this broad group among all malig- 
nancies. 

+ Less than 0.1 percent 
. . . None 



Source: Reference 17 



with additional data on age and sex. References for the morphologic 
classification of selected tumors are cited below: brain tumors; 18 - 19 
lymphoepithelioma; 20 adamantinoma; 21 nasopharynx; 22 ~ 24 liver; 20 
lung; 26 female genital organs; 16 - 27 - 30 spinal cord, 18 and skin. 31 



CANCER RESEARCH 269 

Experimental Tumors. Between 1949 and 1952, research in experi- 
mental tumors was conducted by the Physiology Department of the 
Peking Union Medical College and the Research Bureau of Sanitary 
Engineering, Academy of Medical Sciences. Since 1943 tumor experi- 
mentation has been extended to some 20 other agencies, as mentioned 
earlier. A wide range of studies was initiated covering such areas as 
tumor development, tumor metabolism, tumor immunology, tumor 
transplantation, and tumor therapy. 

A notable experiment in tumor therapy is the use of actinomycin K., 
which was isolated in 1957 from Streptomyces melanochromogenes, ob- 
tained from the soil in South China. 32 - 33 - 34 When used experimentally 
with nitrogen mustard, the drug showed a marked inhibitory effect on 
animal tumors. 35 The drug reportedly was tried on Hodgkin's disease 
patients with encouraging results. Readers interested in the findings of 
this and other experimental tumors may consult the reports in Selected 
Papers on Cancer Research " and the review articles by Hu and Yang, 35 
Chien, 36 and Yang et al. 37 

Recently, the use of kengshenmycin along with other therapeutic 
agents commonly known in Western literature (Table 2 and Appendix 
B) was reported to be effective in the treatment of malignant tropho- 
blastic tumors. 38 This drug reportedly had relatively low toxicity and 
gave favorable results in pulmonary metastasis. 

Independently developed by the Chinese scientists, actinomycin K 
and kengshennycin are known in Western literature as actinomycin D.* 

Promotion of Traditional Anti-Tumor Medicine. In accordance with 
the strong emphasis on integrating Western medicine with the art of 
herb healing, 39 cancer studies directed to the materia medica of China 
have been greatly intensified since 1955. In that year the Institute of 
Epidemiology in the Academy of Medical Sciences began to screen 
anti-tumor herb drugs of simple formula. Subsequently, intracorporeal 
screening for anti-tumor compounds and simple traditional formulas 
in experimental animals was initiated in the Research Institute of Ex- 
perimental Medicine, the Research Institute of Pharmacology (both 
in the Academy of Medical Sciences), and in a number of medical col- 
leges, including Peking, Tianjin, Chungking, Wuhan, Hopei, and 
Hupei. Some of the experimental results were reported in the three 
review articles quoted earlier. 

The emerging convergence of traditional and Western medicine with 
respect to the knowledge of tumors is clearly reflected in the contents of 
a section in Handbook for Barefoot Doctors, 40 a publication of the Re- 



*See C. P. Li: Anti-Cancer Agents Newly Developed in China, chap. 4, unpublished 
manuscript; and Shenghai Municipal Tumor Hospital, Prevention and Treatment of 
Tumors, Appendix 5, Hong Kong. 



270 MEDICINE AND PUBLIC HEALTH 

search Institute of Traditional Medicine of Hunan Province. For ex- 
ample, the information given for the seven common Chinese cancer 
sites (nasopharynx, stomach, rectum, liver, lung, breast, cervix) and 
also for osteosarcoma is generally consistent with Western clinical expe- 
rience (Appendix C). Of particular interest is the recognition of osteo- 
sarcoma, a discussion of which is presented in another paper. 15 How- 
ever, esophageal malignancy, a cancer site of high risk characteristic in 
the Chinese population, is missing. 

The Anti-Cancer Campaign 

Much of the anti-cancer campaign success in New China 
was attributable to the unique operational model adopted, i.e., mass 
social mobilization or patriotic health organization. A good example 
is the activity of the Youth Anti-Cancer Shock Brigade. The Brigade 
was formed in the mid-1950's by the Second Communist Youth League 
Branch of the preclinical departments in the Academy of Medical 
Sciences, 35 consisting mainly of members from the Pathology Depart- 
ment. The organization of the Brigade and the constant support of the 
Party eventually led to the establishment of the Committee for Cancer 
Research of the Academy referred to previously, and to the formulation 
of an ambitious five-year plan for the conquest of cancer. 

Analysis of Microscopically Examined Data. As a politically oriented 
and patriotically motivated work force, the Brigade engaged in ex- 
tensive analysis of microscopically examined material. However, the 
published data per se are generally limited to frequency distributions 
of broad cancer sites and/or histologic types by sex, with occasional 
tabulations by age and other characteristics. In 1958, the Brigade ex- 
amined the records of 27,149 tumor cases from 150,000 surgical speci- 
mens spanning a 38-year period. These specimens were from Depart- 
ment of Pathology of the Academy collection but were mainly those 
of the former Peking Union Medical College. By working round the 
clock, the task of examination and tabulation (about which we have 
no full knowledge) reportedly was completed within eight days! 16 
Also in 1958, members of the Brigade prepared a pathomorphologic 
analysis of 1,895 cases of cervical cancer, which led to the development 
of a morphologic classification system. 41 

Subsequently, the new Peking Medical College assumed the task of 
analyzing 12,678 tumor records, including 2,906 cases of cervical cancer. 
Eight other medical colleges followed suit. They gathered data from five 
institutions on 100,000 tumor cases of all sites. 35 At the Shanghai First 
Medical College the pathology staff members and medical students com- 
pleted in 20 days a morphological analysis of 220,650 surgical speci- 
mens, of which 28,824 were malignant neoplasms. 42 



CANCER RESEARCH 271 

It must be emphasized that the above analytical findings have added 
greatly to our knowledge of cancer morphology and epidemiology in 
China to date. In the 1930s only a few studies of limited scope were 
published. 

Cancer Screening Program and Survey. A cancer screening program 
and survey were carried out at a different level of operation under the 
provocatively phrased "Give Cancer Its Deathblow" campaign. Using 
the standardized procedures set by the National Tumor Conference, 
mass examinations for cervix uteri malignancy were conducted between 
1958 and 1960 in 20 large and medium size coastal and inland cities. 
Two cities were in Inner Mongolia. 13 An intensive public education 
program urged citizens to take advantage of the examination. The 
medical teams, consisting of physicians, interns, nurses, and technicians, 
were given special training for the task. In consonance with the new 
regime's "grass roots" approach to health care, these examinations took 
place in neighborhood hospitals or clinics, and in the health offices of 
factories, schools, and other institutions. In some instances examina- 
tions were conducted in people's homes during evenings. As a result, 
1,693 cases of cancer of the cervix uteri were detected in over one mil- 
lion women aged 25 and older. 

Other examples are cited. In a community of 100,000 population in 
Peking a survey of 8,127 women over 30 years of age was completed in 
less than six weeks. 44 Within a two-year period about 31,000 female tex- 
tile workers throughout the country had participated in the screening 
program. 40 

During the period 1958-1960, a mass survey of the prevalence of 
esophageal cancer was initiated by the Committee for Cancer Research 
of the Academy of Medical Sciences, in collaboration with the medical 
institutions in four northern provinces. 46 The study covered a popula- 
tion of 17 million in both urban and rural areas. The people's com- 
mune was a survey unit for the latter. In order to ascertain incidence 
and mortality rates, annual follow-up surveys in two consecutive years 
were conducted in selected areas. 

While the total size of the population covered in the mass survey and 
screening program in the entire country remains unknown, figures for 
eight cities and four provinces alone indicate that over four million 
persons were reached during 1958-1959. 47 

Cancer Registration. The Gynecologic Malignancy Registry for the 
Nanking area was established in July, 1957. During a five and a half 
year period 1,419 cases were registered. 28 Beginning in January, 1958 
a Cancer Registry was inaugurated in Shanghai under the local joint 
sponsorship of the Health Department and the Statistics Bureau. 
About 19,000 malignancies were recorded for the years 1958 and 



272 MEDICINE AND PUBLIC HEALTH 

I960. 48,49 Incidence rates for each year were computed on the basis of 
general population. 

Cancer Education. Cancer education has always played an important 
role in the anti-cancer campaign, as clearly manifested in the various 
information materials prepared for the public. These include A Popu- 
lar Discourse on the Prevention of Tumors, 50 and Malignant Neo- 
plasms, 52 all written in layman's language. As noted earlier, the edu- 
cational campaign contributed much to the success of cancer screening 
programs. 

Cancer Therapy. Information on cancer therapy in New China is 
extremely limited. The reported efficacious use of actinomycin K and 
kengshenmycin in the treatment of Hodgkin's disease and malignant 
trophoblastic tumors, respectively, was noted earlier. Other therapeutic 
achievements were reported by several authors. 11, 35_37 Of particular in- 
terest is the apparent progress since the founding of the People's Re- 
public in the treatment of malignant trophoblastic tumors (Table 2). 
The mortality figure of choriocarcinoma decreased from 89 to 57 per- 
cent during 1949-1965, and that of chorioadenoma decreased from 26 
to 13 percent. Since 1965 the mortality figure has decreased to 39 and 
5 percent, respectively. More detailed information is contained in 
Appendix B. 

Additional crude statistics on therapeutic results are presented in Ta- 
bles 3 to 5 and Figure A to indicate recent advances in this area. Natu- 
rally, these figures are not strictly comparable with corresponding data 
available for Western countries for such reasons as differences in defini- 
tion (i.e., staging), coverage, selection of patients, and medical ad- 
vances. The 5-year observed survival rates for patients in all stages of 
cervical cancer who were receiving radiation therapy (not shown, based 
on data presented in Table 3 for the three hospitals), ranged from 53 to 
75 percent. This is similar to a 51 percent rate for U.S. registered cases 
for the years 1950-1 954. 72 Other 5-year survival figures for cervical can- 
cer patients receiving radiation or surgical therapy were also compara- 
ble (Table 4). 

In the case of cancer of the esophagus (including gastric cardia), a 
decrease in surgical case fatality from 18.4 to 6.0 percent was noted for 
Fu Wai Hospital during 1947-1961 (Table 5). A similar low rate was 
shown in Table 3 for several other cancers and reportedly paralleled 
those being recorded at the same time in Western literature. The 5-year 
survival rate following resection of squamous cell carcinoma of the 
esophagus was 23.7 percent 60 (Figure A). (Data from Fu Wai Hospital, 
Peking, 1940-1960.) 

Since 1958 traditional drugs and acupuncture have been used inten- 
sively in cancer therapy. Reportedly great progress in the treatment of 



CANCER RESEARCH 



273 



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274 



MEDICINE AND PUBLIC HEALTH 



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CANCER RESEARCH 



275 



Overall 


Stage I 


Stage II 


46.5% 


93.0% 


61.0% 


42.8% 


70.4% 


42.9% 


55.3% 


86.6% 


53.0%, 



Table 4. Five-Year Survival Figures for Patients with Cancer of the Cervix, by Stage 
and Type of Therapy, Specified Hospitals and Years 

Radiation 

245 cases at Tianjin Obsterical and 
Gynecological Hospital. 1952- 
1962 

2,171 cases at Shanghai Tumor 
Hospital, 1950-1956 

398 cases at Shanghai Obstetrical 
and Gynecological Hospital 1952- 
1956 

Surgery 

92 cases (Meigs-Okabayashi meth- 
od) , Shanghai Municipal First 
People's Hospital, 1957-1960 

154 cases at Tianjin Central Obste- 
trical Hospital and Shanghai 
Municipal First People's Hos- 
pital, 1963-1964 

225 cases at the First Hospital, 
Peking Medical College, 1949- 
1964 

1,181 cases in Shanghai, Tianjin, 
and Wuhan, 1965 

757 cases at Shanghai Tumor 
Hospital, 1951-1961 

Source: References 53-59 



88.3% 



93.7% 



95.1% 



93.6% 



55.5%, 



62.5% 



62.5% 



95.0-100.0% 62.0-77.0% 

95.2% 50.0% 



Table 5. Surgical Case Fatality by Selected Cancer Sites, Specified Hospital, and Years 



Tumor 



Source of Data 



Surgical Case Fatality 
(Percent) 



Esophagus 



Esophagus 
(including 
gastric cardia) 



1,562 cases at 18 hospitals, about 
1950-1959 



161 cases, Fu Wai Hospital and Can- 
cer Hospital, Peking 1960 

202 cases, First Hospital Peking 
Medical College, 1957-1962 

210 cases, Provincial Second Hos- 
pital, Shangtung 

152 cases, Chinese Union Medical 
College, 1947-1954 



10%; 3-5%, 1956-1959 
(30-40% before 1949, 
12-25 cases) 

6.4% 



4.9% 



12.5% 



18.4% 



276 



MEDICINE AND PUBLIC HEALTH 



Table 5. (continued) 



Tumor 



Source of Data 



Surgical Case Fatality 
(Percent) 



Esophagus 
and stomach 



Stomach 



Colon 

Rectum 
Liver 

Pancreas and 
duodenum 

Lung 

Breast 

Kidney 
Cervix 



Brain 



Fu Wai Hospital, Peking 1947-1961 
209 cases, 1947-1951 
181 cases, 1952-1956 
649 cases, 1957-1961 

112 cases (incl. 52 cases of total 
gastrectomy), Peking Union Hospital, 
1948-1958 



66 cases, Chang Chun Medical Col- 
lege Hospital (NE China) about 1960 

895 cases, three hospitals in Shang- 
hai, 1949-1959 

83 cases, Chung Shan Hospital, 
Shanghai First Medical College, 
1950-1955 

102 cases, Chung Shan Hospital, 
Shanghai First Medical College 1950- 
1956 

47 cases, Peking Union Hospital, 
1948-1958 

66 cases, 1970 

130 cases, Chung Shan Medical Col- 
lege Hospital, Canton, 1941-1961 

66 cases, 1960 



129 cases (88 total pneumonectomy 
and 41 lobectomy cases), about 1959 

2,549 radical mastectomy cases in 10 
cities, 1951-1960 

61 cases, about 1959 

780 cases (1st and 2nd stages) in six 
large cities, 1949-1960 

92 cases, Shanghai First People's 
Hospital, 1957-1960 

757 cases, Shanghai Tumor Institute, 
1951-1961 

22 cases, about 1959 



9.1% 
18.6% 
11.1% 

6.0% 

10.7% (12%, 1921- 
1941, incl. 2 total 
gastrectomies out of 
25 cases) 

1.6% 
6.7% 



2.4% 



3.9% 



0% (22.5%, 1922- 
1941) 

14.8% 
25.4% 



14.8% 

10.0% 

0.2% 

4.9% 
0.6% 

2.2% 

0.7%, 

13.6% 



Source: References 18, 36, 44, 56, 61-65, 67-71 



CANCER RESEARCH 



277 



cancers of esophagus, stomach, colon, and breast was made as a result of 
combination of traditional and Western medicine. In patients with cer- 
vical malignancy, reports said that some traditional drugs reduced cycli- 
cal changes in a manner similar to radiation therapy. The drugs were 
said to promote substantial relief of pain and distress in many ad- 
vanced cases. 66 The report of the Conference on Esophageal Cancer, 
involving four provinces and one city, said over 50 percent of patients 
treated with herb medicine were cured. 36 In view of the usual poor 
prognosis of this malignancy in Western countries, such a high figure 
invites close scrutiny. 

The herb drugs, which have been used as antineoplastics, are said to 
be numerous, and are partly listed in a recent paper. 73 Two drugs, lith- 
ospermum officinale and pei yao (produced in Yunan province), re- 
portedly were beneficial in treatment of choriocarcinoma. 66 The efficacy 
of these drugs can be established only through standardized use and 
controlled clinical trails on an extended scale. 

Conclusion 

The reported achievements in organizing cancer research 
and preventive programs in the People's Republic of China are largely 
attributable to the mass-social-organization model adopted. Admittedly, 
our current knowledge of New China's progress in these areas is ex- 
tremely limited. We look forward with interest to more information in 
future years. 



(%) 100 i 
90 - 
80 
70 
60 ■ 
50 
40 
30 
20 
10 






















Year after 
operation 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


No. of cases 
followed 


245 


193 


139 


98 


76 


73 


70 


63 


58 


53 


No. of survivals 
at follow-up 


171 


88 


48 


28 


18 


15 


14 


12 


9 


6 


Survival rate 

(%) 


70.0 


45.6 


34.5 


28.6 


23.7 


20.5 


20.0 


19.0 


15.5 


11.3 



Fig. A. Survival rate of patients at 1-10 years after resection of squamous cell 
carcinoma of the esophagus, Fu Wai Hospital, Peking, 1940-1960. 



278 MEDICINE AND PUBLIC HEALTH 

The massive statistical results of the Chinese anti-cancer movement 
should interest students of cancer epidemiology, since they provide use- 
ful information for gaining new insights into this disease. The findings 
of a companion study, based on such materials, are presented in a sepa- 
rate paper. 15 

Appendix A. List of Known Organizations 
Engaging in Tumor Research 

Organizations in the Chinese Academy of Medical Sciences 
The Tumor Institute (350 beds) 
The Research Institute of Experimental Biology 
The Research Institute of Pharmacology 
The Research Institute of Experimental Medicine 

The Research Institute of Tumor Etiology 

The Research Institute of Tumor Therapy 

The Research Institute of Tumor Immunology 

The Research Institute of Tumor Metabolism 

The Research Institute of Human Tumor 

Heterologous Transplantation 

The Research Institute of Human Tumor Tissue Culture 
The Institute of Epidemiology 
The Committee for Cancer Research 
The Research Bureau of Sanitary Engineering 
The Choriocarcinoma Study Section 

Other Organizations 

The Committee for Cancer Research in Shanghai, Tianjin, 

Chengtu and other cities 
The Tumor Hospital, Shanghai First Medical College 
The Huanan (South China) Cancer Hospital, Canton (140 beds) 

Department of Radiology 

Department of Internal Medicine 

Department of Gynecology 

Department of Chest and Abdomen 

Department of Head and Neck 
The Hangchow Tumor Hospital (Chekiang province) 
The Taiyuan Tumor Hospital (Shansi province) 
The Tumor Department, Tianjin Hospital 
The Cancer Research Unit, Szechuan Medical College 
The Physiology Department, Peking Union Medical College 
Medical Colleges in Tianjin, Chungking, Wuhan, Hopei, Hupei, 
and other areas 



CANCER RESEARCH 279 

Appendix B. 

Excerpts from 

Progress in the Treatment of Malignant Trophoblastic Tumors 
During The Last Two Decades in the Peking Fan Ti Hospital 

(Scientific Report, 1971) 

During a period of 20 years from 1949 to 1968, a total of 581 cases of 
malignant trophoblastic tumors, consisting 294 cases of choriocarci- 
noma and 287 cases of chorioadenoma destruens, were admitted into 
this hospital. 

The therapeutic results in 3 different periods is shown in Table 1. 
(See Text Table 2). 

Diagnostic criteria and clinical staging. 

Clinical diagnosis was based on history, physical examination, roent- 
genological examination of the lungs and determination of the urinary 
chorionic gonadotrophin. In some of the patients treated by chemother- 
apy alone for the preservation of fertility, hysterosalpingography and 
occasionally pelvic arteriography were performed. Electroence- 
phalographic examination was made in all cases suspected of brain me- 
tastasis. When metastasis of the liver was suspected, hepatoscanning was 
performed. 

Pathologic diagnosis was mainly based on the uterine specimens and 
autopsy materials with the exception of a few taken from surgically re- 
moved vaginal, pulmonary metastatic nodules or other materials. The 
final diagnosis in most cases was based on pathologic examinations. 

The criteria of clinical staging are: Stage I: the lesion is limited to 
the uterus; Stage II: the lesion has extended outside the uterus but 
within the genital organs; Stage III: pulmanory metastasis; Stage IV: 
generalized metastases to the brain, liver, kidney, spleen, intestine, skin, 
etc. 

The therapeutic results in relation to the clinical staging in 3 periods 
are shown in Figure B. 

Therapeutic methods. 

The methods of administration of different chemotherapeutic agents 
are listed in Text Table 2. 



280 



MEDICINE AND PUBLIC HEALTH 



Clinical 

Stage I 



III 



IV 



Total 



1949.1 


33.3% 

I 2/6 | 


100% 




100% 




100% 




89.2% 


I 
1958.7 


8/8 




11/11 




12/12 




33/37 



1966.1 



1968.12 



1958.8 

i 


0/15 


33.3% 

I 2/6 | 


40.8% 


85.3% 




88.9% 




I 


29/34 




24/27 




57.3% 


1965 12 




75/131 




| 20/49 



12.5% 
1-2/16- 



11.1% 
— 1/8-, 



28.9% 
1 "/38l 



51.2% 



22/43 



63.1% 



12/19 



38.9% 



49/126 



Fig. B. Comparison of mortality rate in relation to clinical staging. 



Table 2. Method oj administration of chemotherapeutic agents 



Agent 


Route 


Daily Dosage 


Duration of 
course (days) 


Interval 
courses 


between 

(weeks) 


6MP 


Oral 


6.0-6.5mg kg in 
2 divided doses 


10 




3 


-4 


MTX 


Oral 


0.45-0.5mg kg in 
2 divided doses 


5 




3 


-4 




i.v. drip 
Intrathecal 


10-15 mg 6-8 
10-15 mg each time 




2 


-3 


5Fu 


i.v. drip 


25-30mg kg 


10 






2 




Local injection 


250-500 mg each 
time 


10 






2 


KSM 


i.v. drip 


300-400 meg 


10 






2 


5Fu&: 
KSM 


i.v. drip 


5Fu 23-25mg/kg 
KSM 300 meg 


8-10 






3 



CANCER RESEARCH 



281 



Appendix C. Primary Cancer Sites Commonly 
Seen in China 

Excerpts from 
Handbook for Barefoot Doctors, Chapter 6, Section 7, Table 3. See reference 40 



Primary Site 



Clinical and Demographic Characteristics 



Nasopharynx 



Stomach 



Rectum 



Liver 



Lung 



Breast 



Cervix 



Osteosarcoma 



Usually seen in the youths and young adults; feeling by patient 
of presence of some foreign body in the nasopharynx; nasal 
discharge mixed with bright red blood; rapid loss of weight, 
swelling of lymph node in the neck; frequent headache; numb- 
ness of the head and neck region. 

Usually accompanied by long history of ulcers; loss of appetite 
and indigestion; hiccuping; loss of weight; anemia; weakness; 
development of localized lump; bleeding in the upper digestive 
tract or passing of dark tarry stool; obstruction appearing in the 
advanced stage; metastasis to the lymph node of the left 
clavicle. 

Usually seen in females middle aged and above; relatively slow 
worsening of the disease; change in bowel movement in the 
initial stage; bloody, mucous stool becoming thin; feeling of 
fullness in the stomach; diarrhea; in the advanced stage pain 
developing in the lower abdomen and metastasis to the sacrum; 
lump can be felt by digital examination. 

Usually seen in middle aged males; rapid worsening of the 
disease; great loss of weight and appearance of other symptoms 
within weeks; most patients have constant pain in the upper 
right abdominal area near the liver; jaundice in the advanced 
stage, accompanied by fever, anemia, ascites, etc.; swelling and 
hardening of the liver in most cases, along with development of 
nodes on the surface. 

Usually seen in old males; chronic coughing; bloody discharge; 
chest pain or hemothorax in the advanced stage: swelling of 
lymph node in the lung; metastasis to distant organs by the 
blood stream. 

Usually seen in females aged 40 and over; localized swelling or 
fixation of lump in the breast; retraction of nipple; orange-peel 
appearance of skin; painless and solitary in the beginning, fol- 
lowed by metastasis to the armpit or further distant area or by 
erosion. 

Usually seen in females aged 40 and over; possible association 
with cervicitis; increasing flow in menstruation; frequent passage 
of blood-tinged discharge; most often metastasizing to the cavity 
organs; pain in lower abdomen and the lower back. 

Usually seen in the upper and lower limbs of young persons; 
worsening localized pain in the evening; sleeplessness; loss of 



282 MEDICINE AND PUBLIC HEALTH 



Primary Site Clinical and Demographic Characteristics 

appetite; rapid loss of weight; atrophy of the affected limb; 
swelling in the node; skin becoming locally distended and shiny; 
prominent veins; localized bursting pain; low fever; metastasis to 
the lung. 



CANCER RESEARCH 283 

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Squamous Cell Carcinoma of the Esophagus." In Chinese Academy of Medical 
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63. Hu, S. K., Ts'ai N. C, and Shou, N. H.: "Treatment of Carcinoma of Esophagus: 
Analysis of 210 Cases," Chinese J. Surg. (Chung Hua Wai K'o Tsa Chih): 
6:655-658, 1958. (in Chinese) 

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(Chung Hua Wai K'o Tsa Chih) 6:1099-1101, 1958. (in Chinese) 

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(in Chinese) 

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In Chinese Academy of Medical Sciences, The (ed.): Selected Papers on Cancer 
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Surg. (Chung Hua Wai K'o Tsa Chih) 6:1089-1093, 1958. (in Chinese) 

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tended Radical Mastectomy for Carcinoma of the Breast." In Chinese Academy 
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1967. 



MENTAL DISEASES AND THEIR TREATMENT 



Ruth Sidel, M.S.W. 



INTRODUCTION 

The material in this paper is based on observations made 
during a one-month visit by my husband and me to the People's 
Republic of China in September-October 1971 as the guests of the 
Chinese Medical Association. 

To understand in depth a society whose history, culture and organiza- 
tion is vastly different from one's own is impossible in such a brief 
period of time. What we did attempt was to get a glimpse of some 
of China's problems, goals and solutions. Looking at mental health 
facilities is a particularly difficult task since many of the premises 
involved in psychiatric care differ greatly from ours in the West. For 
those of us trained in Freudian thinking, the task involves putting our 
assumptions to one side, for a time, and examining a very different view 
of man and his psyche. Of crucial importance in the Chinese view of 
man is the belief in man's ability to change, given a sympathetic envir- 
onment and "education and re-education." Underpinning this view, 
and in fact running through all activities in the society, is politics. As 
our Chinese hosts frequently told us, "We put politics in command." 
And as we shall see, politics is in command in the area of mental 
health. 

The organization of Chinese society today must be considered in any 
discussion of mental health. It seems to be a society of great consensus; 
similar customs and mores apply to vast numbers of the population. 
Basic needs such as food, clothing, housing, jobs, education and medi- 
cal care are now guaranteed to essentially the entire population, albeit 
at a minimal level. No one is left to fend for himself; the population 
both in the cities and in the countryside is divided into small units 
characterized by both self-reliance and mutual help. The individual is 

287 



288 MEDICINE AND PUBLIC HEALTH 

expected to work hard and participate extensively in local affairs but is 
also cared for by his family, neighbors or associates at work when he is 
in need of such care. In addition, there is no doubt little tolerance for 
asocial or anti-social behavior and great pressure is undoubtedly applied 
to assure conformity to the approved way of life. 

Our view of Chinese mental health services was extremely limited. 
We visited the psychiatric department of the Third Peking Hospital 
and the Shanghai Mental Hospital. We talked with doctors, nurses and 
members of the Revolutionary Committees of both hospitals at some 
length. We also were able to gather general information on the struc- 
ture of Chinese society and its relationship to mental health from our 
hosts of the Chinese Medical Association. 

The "Bitter Past" 

Long before Western psychiatric theories entered Chinese 
medical thinking, there were 2 divergent streams of thought which 
explained mental illness: the philosophical or medical approach, and 
folk beliefs and folk medical practices. Both of these streams of 
thought had great impact on modern Chinese psychiatric thinking. 

To look initially at the philosophical or medical body of thought, ac- 
cording to ancient Chinese medical writings, all disease including men- 
tal illness was caused by an imbalance of two forces: the Yin and the 
Yang. According to Ilza Veith, "These two forces which stand for the 
negative and the positive, the dark and the white, the moon and the 
sun, the noxious and the beneficial, also denote the female and male 
elements, both of which are ever present in man and woman alike. Dis- 
ease arises when the proportions of the two elements begin to vary from 
the normal." 1 The imbalance between the Yin and the Yang was 
thought to be caused by deviation from the Tao, or the "Way," which 
provided the guide for all morality and human conduct. The Tao can 
be further thought of as being an "ethical superstructure" that "pro- 
vided for all eventualities in life and for all essential types of interper- 
sonal relationships." 1 Once transgression against this ethical superstruc- 
ture occurred, the way to a return to health was through a return to 
Tao. 

While there is no supernatural element in the philosophical or medi- 
cal explanations of mental illness, the popular or folk beliefs about the 
origins of mental illness are almost entirely based on supernatural 
causes. And while the believers in Tao saw the mind and the body as 
indivisible, popular beliefs saw the mind and the body as separate enti- 
ties. Spirits and demons were thought from earliest times to be responsi- 
ble for many of the ills that befell man. Spirits were thought to be every- 
where, ". . . in the water, the caves, the trees and graves, they lurked 



MENTAL DISEASES 289 

in the soil and under rocks. They swarmed about the homes of men, in 
populated as well as in isolated regions and, according to many tales, 
their favorite abodes were the privies, where man is alone and helpless 
and flight difficult." 2 Once a demon or spirit entered a person and 
made him ill, they needed to be exorcised. The first exorcists were 
members of a priesthood called Wu which to the present day has the 
meaning of wizard, witch, expeller of demons. Wu is first encountered 
in the "Rites of the Chou dynasty" (1122-255 B.C.) and it came even- 
tually to be synonomous with the word for physician, Wu-i meaning 
"magical physician." 2 The Wu who might be either male or female was 
thought to be able to cure because he had a greater proportion of Yang 
than ordinary people. To exorcise the spirit or demon that had entered 
the sick person, the Wu might put the patient into a deep sleep, might 
dance around the ill person, and was likely to inflict wounds upon him- 
self as a method of cure. 

Among the spirits which might enter a person, the spirits of the dead 
were greatly feared, particularly those who had not had proper funeral 
observances or those who had died through violence. It was thought 
that the spirits of the dead could steal the souls of the living particu- 
larly while the living were asleep and the soul was occupied with 
dreams. Since the spirits of the dead were thought to be so powerful, 
much of the work of the medical priests was in attempting to appease 
their hostility. One particular group of spirits were thought to be espe- 
cially powerful, the T'ien Ku, otherwise known as "Celestial Dog." 
They were thought to be able to speak to their victims, inflict amnesia 
upon them, and particularly disturb young sons. 

The fox was also thought to have great powers both in the folklore of 
China and of Japan. He was thought to be so powerful that he could 
not only bring on mental disease but also could impersonate those who 
could cure mental illness, thereby causing massive confusion. During 
the Han Dynasty and the Han period of literature (206 B.C-280 
A.D.) the fear of foxes was widespread. 2 The fox seems to have played 
a great role in sexual seductions and assaults, sometimes occupying the 
bodies of young women or sometimes of men. The following passage 
from the Hsuan-chung-chi , written in the first few centuries A.D. dem- 
onstrates the power the fox was thought to have: 

"When a fox is 50 years old, it becomes a beautiful female ... or a grown 
up man who has sexual intercourse with women. Such beings are able to 
know things occurring at more than a thousand miles distant; they can 
poison men by sorcery, or possess them, and bewilder them, so that they 
lose their memory and knowledge. And when a fox is a thousand years old, 
it penetrates to heaven, and becomes a Celestial Fox." 2 

Since the mentally ill person was thought to be possessed by a spirit 



290 MEDICINE AND PUBLIC HEALTH 

or demon or fox, the onset of illness was swift and the cure might be 
equally sudden. The Wu by his ministrations could exorcise the demon 
suddenly; swift exorcism led to a belief in the curability of mental ill- 
ness which has seemed to carry through to the present. The theory of 
possession by demons also leads logically to the attachment of no blame 
to the patient himself thereby reducing the stigma attached to mental 
illness. 

Other popular beliefs about the origin of mental illness were that 
one might have been guilty of a misdeed in one's previous life, that 
one's ancestors might have offended the gods who are now punishing 
the offspring, that the god of the wind is using the insane man's home 
as a temporary residence and that his spirit is living in the ill person's 
body, that some organ inside the body is deformed or has lost its func- 
tion, or that the circulation of blood within the ill person is running in 
the opposite direction from that of the normal person. It was felt that 
mental control was through the heart and if the heart loses control, the 
body is then without direction. 3 

These were some of the prevalent beliefs of the causes of mental ill- 
ness when the first mental hospital was opened in Canton in 1897. Al- 
though it started with only thirty beds and increased in size to 500 
beds, it was closed in the 1930's. 1 The first Department of Neurology 
was established in 1921 at the Peking Union Medical College, 10 years 
after that medical school was established. 4 The growth of psychiatry 
and neurology in China from 1921 to 1949, when the Communists took 
power was very slow; in 1948 there were approximately 1,000 beds for 
psychiatric patients in all of China. 4 

In 1949 there were only 4 psychiatric hospitals in China, one each in 
Peking, Shanghai, Canton, and Nanking; patients were often cruelly 
treated, bound to their beds and barely given any psychiatric care. 4 By 
the 1930's and 1940's, most people suffering from mental illness were 
still being kept in their homes with their families; if they were found 
in the street doing anything wrong they might be "thrown into prison 
and treated as if they were criminals. If they are harmless and wander 
in the streets, they are mocked and laughed at and are often stoned." 3b 

Estimates of the incidence of mental disease in China in the mid- 
1930's have ranged from as low as one person in every thousand or 
400,000 mentally-ill people to one in every four hundred or one million 
to one million two hundred and fifty thousand. 30 Widespread poverty, 
violence, starvation, and the brutalizing effect these conditions had on 
family life made for fertile ground for mental illness. The cruelty to 
which women were subjected, being sold into marriage at a young age, 
having to serve her husband's family, being brutally treated by her hus- 
band and particularly by her mother-in-law, and bearing many chil- 



MENTAL DISEASES 291 

dren, most of whom might well die, drove many women to suicide and 
undoubtedly drove others to mental illness. 

Prior to 1949 venereal disease was an important cause of mental ill- 
ness. The earliest estimates of the existence of prostitution in China are 
from the Chow Dynasty in 650 B.C. Venereal disease appears to have 
been introduced during the time of the Ming Dynasty from 1488 
through 1521 A.D. and started from Kwangtung Province and spread to 
the north. 3d At the time of Liberation the prevalence of syphilis was 
said to be ten percent in the national minority areas and five percent in 
the cities. 5 Although there was some effort to control and treat venereal 
disease, medical techniques were hindered by the popular belief that ve- 
nereal disease was a logical punishment for misdeeds. 3e It was not until 
Liberation that the houses of prostitution were closed and venereal dis- 
ease systematically rooted out and treated. 

Another major cause of mental illness prior to 1949 was drug addic- 
tion. It has been estimated that there were 300,000 addicts in Peking 
alone in the mid-1930's. 6a In 1935 the Nationalist government launched 
a six-year program aimed at "the total suppression of the chronic use of 
morphine and heroin" within two years and opium within six years. 
Compulsory treatment was inaugurated, including two to three weeks 
of hospitalization followed by hard labor in Peking and Nanking to 
build up the addict's physical condition. There were a large percentage 
of relapses and in 1937 addicts began to receive severe punishment, 
some recidivists were executed and others sent to prison. 65 

From Liberation to Cultural Revolution 

From the time the Communists took power on the mainland 
in 1949, which they call "Liberation", until 1965, the government put 
great stress on medical care. By 1952 when the Chinese Society of 
Neurology and Psychiatry, affiliated with the Chinese Medical Associa- 
tion in Peking, was established, there were only 100 neuropsychia- 
trists in China and by 1967 this figure had risen to 436. 

By 1957 the number of psychiatric beds had been increased to 20,000 
and new methods of treating mentally ill patients had been introduced. 
Isolation and the binding of patients were prohibited and work therapy 
was introduced. Before the Cultural Revolution all of the medical 
schools in China were teaching courses in psychiatry and neuropsychi- 
atric research was being carried on widely. From 1958 through 1961 elec- 
troencephalographic research was being carried on as well as research 
into schizophrenia. 4 Psychiatric services were spreading at an even 
greater rate in China in the latter 1950's and early 1960's. There have 
been reports of treatment of mental illnesses in the autonomous regions 



292 MEDICINE AND PUBLIC HEALTH 

of Inner Mongolia and in Urumchi, which is the center of the Sinkiang 
Uighur autonomous region. 4 

Before the Cultural Revolution, traditional medicine including acu- 
puncture, ignipuncture, breathing exercises, and the use of herb medi- 
cines as well as Western medicine were used for the treatment of men- 
tal disease. Acupuncture will be dealt with in greater detail later in 
this paper. Ignipuncture is "treatment by means of thermal excitation 
through various methods of cautery and burning at empirically deter- 
mined points of the body." 4 Sometimes acupuncture and ignipuncture 
were combined in a course of treatment which is then called Chen chu 
and dates back 2,000 years in the treatment of psychoses, neuroses and 
headaches. 

The breathing exercises used were similar to those used by Buddhist 
monks and therapeutic results have been obtained after regular use of 
breathing exercises, morning and evening for several months. 4 

The Current Scene 

Since the Cultural Revolution there has been increased 
emphasis in all branches of medicine on combining traditional medi- 
cine with Western medicine. While the Chinese have been combining 
traditional and Western medicine since 1949 in other branches of 
medical care, the psychiatric sphere seems to have concentrated more 
on Western methods of treatment and to have neglected traditional 
techniques from the time of Liberation until 1965. Using the slogan 
"Let the past serve the present and let the foreign serve China", 
Western-trained doctors have been revamping their psychiatric services 
to include traditional methods and political techniques adopted by the 
society at large since the Cultural Revolution. 

As in all other institutions in China since the Cultural Revolution, 
the psychiatric hospital is now run by a Revolutionary Committee con- 
taining the three-in-one combination of the People's Liberation Army, 
cadres (political workers) and members of the mass. The mass includes 
those people who work in any institution; in a mental hospital it in- 
cludes the doctors, nurses, cleaning help and auxiliary workers. The 
Revolutionary Committee also often includes another three-in-one com- 
bination of aged people, middle-aged people and young people. The 
Revolutionary Committee at the Shanghai Mental Hospital, which was 
founded in 1958, is made up of 15 members, 11 men and 4 women. The 
hospital has 13 wards, five for women and 8 for men comprising a total 
of 916 beds. The staff includes 61 doctors and 169 nurses. The methods 
currently being used in treating mental illness include collective help, 
self-reliance, drug therapy, acupuncture, "heart-to-heart talks," follow- 
up care, community ethos, productive labor, and the teachings of Mao. 



MENTAL DISEASES 293 

Collective help. With the participation of members of the People's 
Liberation Army in the administration of hospitals since the Cultural 
Revolution, some psychiatric hospitals are using the Army model of 
organization and are dividing the patients on the wards into divisions 
and groups so that they can become a "collective fighting group in- 
stead of a ward." Within these "fighting groups" the patients who are 
getting better are paired with newer and sicker patients so that they 
can help each other with "mutual love and mutual help." 

Self-Reliance. The patients themselves are encouraged to investi- 
gate their own disease, to investigate their symptoms and to under- 
stand their treatment. They are encouraged to study themselves in 
order to recognize their own condition and to prevent their own 
relapse. 

Drug Therapy. Seriously ill patients are given chlorpromazine (Thor- 
azine) though evidently in smaller doses than before the Cultural 
Revolution. Insulin shock and electric shock therapy have been elim- 
inated since the Cultural Revolution. 

Acupuncture. Three kinds of acupuncture are used for certain forms 
of schizophrenia. 1) acupuncture needles placed in the temples or 
behind or in front of the ear hooked up to a battery box for 3-5 
minutes at a time, once or twice a day for a 40 to 45 day course; 2) 
acupuncture of the ear; and 3) acupuncture on the body, on the legs 
and the arms for relief of excitement, catatonia, and depression. This 
third form is generally done from 15 to 20 minutes three times a day. 

"Heart-to-heart talks." A psychiatrist meets with patients individu- 
ally or in small groups at regular intervals to discuss the patients' 
problems and to help them understand their illness more completely. 
We were told that the most important form of treatment is the rela- 
tionship between the psychiatrist and the patient. 

Follow-up care. After the patient is discharged he is followed up 
every two weeks and then monthly in the out-patient department. 
Sometimes a doctor or a nurse from the staff of the hospital will make 
a home visit. Before discharge a doctor will have visited the patient's 
place of work and will make sure the patient returns to a job which is 
best for his mental health. His job has been kept for him until his 
return but it may be that another task within his work unit would 
better suit his mental health needs. Often the patient is kept on 
chlorpromazine after discharge but on a smaller dosage. 

Community ethos. Every neighborhood, both urban and rural, is 
organized under the direction of a Revolutionary Committee, again 
made up of members of the People's Liberation Army, cadres, and the 



294 MEDICINE AND PUBLIC HEALTH 

mass (the people who live in the neighborhood). The elected members 
of the Revolutionary Committee provide the social services, mediate 
disputes, do marital counseling, and in general look after the people in 
the neighborhood. When a patient is about to be discharged from a 
mental hospital he is under the "special concern" of members of the 
Revolutionary Committee in his neighborhood as well as his family 
and friends and this community concern plus the assurance of his job 
and family waiting for him helps ease the transition from hospital to 
community. 

Productive labor. As in the larger society where all members are en- 
couraged to do productive labor, in the hospital they are also en- 
couraged to do what we in the West would call occupational therapy. 
Patients were seen folding bandages and preparing medications for the 
out-patient department, and doing work for a local factory such as 
making the covers of toothpaste tubes. The factory pays the hospital 
for the work done by the patients and the hospital then uses this 
income to provide special services for the patients. 

The Teachings of Chairman Mao Tse-tung. Running through this 
entire gamut of treatment techniques is the philosophy of Chairman 
Mao. Inspired by his maxim, "Heal the wounded and rescue the dead," 
patients and workers alike study his writings, "On Practice," "On 
Contradiction," "Where do correct ideas come from?" and the three 
constantly-read articles, "Serve the People," "In Memory of Norman 
Bethune" and "The Foolish Old Man Who Removed the Mountains." 
Patients are organized into study groups to study daily these writings. 
They are encouraged through these writings to understand "objective 
reality" rather than functioning on the basis of "subjective thinking." 
They "arm their minds with Chairman Mao's thought during their 
stay in the hospital in order to fight their disease." 

The Patients 

In the psychiatric department of the Third Hospital in 
Peking which has two wards, one male and one female, including 90 
beds, we attended a performance given by the patients. The perform- 
ance was given in a large room which they call their club and was 
attended by perhaps 50 patients, wearing red pajamas, and red and 
white striped robes. Four patients gathered around a table to tell us 
and the other patients "How I used Chairman Mao's thought to con- 
quer difficulties." First, a 32 year old man with the diagnosis of para- 
noid schizophrenia spoke; he had been in the hospital for three months: 

"At the time of the last spring festival I had a quarrel with my wife. 
She said she wanted to divorce me and I was surprised. I returned 



MENTAL DISEASES 295 

to work but I was suspicious of my wife and kept thinking that she 
would divorce me. At that time my wife was not working in Pe- 
king and I asked to have her transferred to Peking and asked her 
to send my letters back. We quarrelled a lot because I insisted that 
she wanted to divorce me and she said that she did not. 

"During my early period of admission I did not know that I had 
mental trouble. Gradually I recognized that something was wrong 
in my mentality and I gradually recognized that I had to make a 
case analysis of the causes of my disease in order to facilitate treat- 
ment and prevention. 

"My trouble was that I had subjective thinking which was not ob- 
jectively correct. My wife had not written letters wanting to di- 
vorce me; my wife actually loves me. My subjective thinking was 
divorced from the practical condition and my disease was caused by 
my method of thinking. I was concerned with the individual per- 
son; I was self-interested. I haven't put revolutionary interests in 
the first place but if I can put the public interest first and my own 
interest second I can solve the contradictions and my mind will be 
in the correct way. From now on I will study Chairman Mao and 
apply his writings." 

The second patient who spoke was a 38 year old grey-haired man 
with a friendly open face. 

"My main trouble is suspicion. I think my ceiling is going to fall 
down; when big character posters are up I think it is criticism of 
myself; and when somebody is gossiping I think they are talking 
about me. 

"After I was admitted to this hospital I gradually recognized my ill- 
ness. As Chairman Mao says, when we face a problem we have to 
face it thoroughly, not only from one side. When I am discharged 
from the hospital, the doctors have said that I should have some 
problem of investigation in my mind. When I am in touch with 
people they have suggested that I make conclusions in my mind 
after investigation not before investigation, in order to see if what I 
suspect to be true is just subjective thinking or is objectively cor- 
rect. By studying Chairman Mao, we can treat and cure disease." 

This patient was treated with chlorpromazine, 12 mg at noon and 
14 mg in the evening. He also received consultation from a traditional 
doctor and was treated with traditional medicines. 

The third patient who spoke was a woman in her twenties. 

"I was a graduate of junior middle school and in 1969 was sent out 

to work in an outlying province. I was admitted 5 months ago to 



296 MEDICINE AND PUBLIC HEALTH 

this hospital but I am getting all right now. My main trouble is au- 
ditory hallucinations. I hear something in my ear saying, 'What is 
below your pillow?' I found old magazines on the subject of a bio- 
logical radio apparatus and I came to the ridiculous conclusion 
that a special agent is investigating me by means of this biological 
radio apparatus. I became agitated and heard loud speeches in my 
mind which gave me a very bad headache. During the midst of my 
torture I was sent to the hospital and received medication. My 
headache is much better but I still have hallucinations. 

"The doctors organized a study class of Chairman Mao's works and 
I joined the study class and studied the five works. I studied my 
hallucinations and gradually recognized that they were non-exis- 
tent. I found that investigation is like a pregnancy and solving 
problems is like delivering a baby. As I investigated my problem I 
gradually recognized that the biological radio was non-existent. 
Now I still have some hallucinations but after ten minutes I recog- 
nize that they are not real. Now whenever I have hallucinations, I 
study the works of Chairman Mao and attract my mind and my 
heart so I will get rid of my trouble. 

"My treatments consist of acupuncture, medicine, herb medicine, 
and study. Also I am considering what happens in the whole world. 
I talk with doctors and patients; I do physical exercises; I have not 
completely recovered yet but I have faith I will get better and will 
win the struggle." 

The fourth patient, a young woman who was a middle school grad- 
uate with a diagnosis of schizophrenia, had been hospitalized for two 
months but had been discharged when her disease improved. She re- 
turns periodically for a check-up and on the morning we visited the 
ward she had been invited back to talk with the new patients and to 
help teach them how to arm themselves with Chairman Mao's thought. 
She was dressed in street clothes and told us the following story: 

"I was a senior middle-school graduate in 1967 but my health was 
not good at that time. I had heart trouble and arthritis and was not 
sent out to work like my classmates. Last April I was called to have 
a discussion with regard to my work and I got my mental trouble 
at that time. 

"I was born in the new society and therefore have not suffered as 
people did in the old society. I was educated for more than 10 years 
and then rested at home for 2 years due to my illnesses. Thus I was 
divorced for 12 years from practice, class struggle and revolutionary 
experience. I was a 'hot-house flower.' 



MENTAL DISEASES 297 

"I knew that sick people were kept in Peking and not sent out to 
remote areas and I thought day and night about where I would 
work. I had a fixed opinion that I had to work here in Peking, not 
elsewhere. I didn't want to eat and I didn't want to drink. I 
dreamt of being a People's Liberation Army woman at that time 
and had suspicions and fantastic ideas whenever I saw a member of 
the P.L.A. or a P.L.A. car I thought it would take me to the Peo- 
ple's Liberation Army. 

"During my early period of admission I could not manage myself. I 
threw pillows through windows and had to be fed. I thought I was 
going to be poisoned here and thought I had to struggle against the 
hospital. When other patients sang Army songs I thought the 
P.L.A. was here already. Gradually I realized that the doctors and 
nurses were here to serve the patient. They washed my hair and 
clothing and I gradually realized that this is a hospital. I then par- 
ticipated in a study group and studied the Five Constantly-Read 
Articles for two weeks. I learned that my hallucinations and suspi- 
cions were not real and found that studying in a study class was a 
good way to solve one's problems. I understood that one has to 
have knowledge before experience and then try to understand objec- 
tive reality. 

"When a member of the P.L.A. visited the hospital I thought it was 
for me and I raised the issue in my study group. The doctors told 
me it was just a visit by that member and it was not for me and I 
believed them. 

"I was discharged over three months ago and although my new job 
was supposed to be arranged July 1, it has not been arranged yet 
but I now have full faith in the Communist Party and the Govern- 
ment and know that they will arrange a job for me later on. Until 
then I will continue to take my medicine and have close contact 
with the medical people in this hospital." 

The doctors at the Shanghai Mental Hospital felt that schizophrenia 
was the most common diagnosis of their patients. Over 50% of the pa- 
tients are schizophrenics. The department also admits a small percent- 
age of patients who have physical illnesses with psychiatric complica- 
tions such as those patients with disturbed liver function, epilepsy and 
heart diseases. They felt that paranoia was the most common form of 
schizophrenia and that depression, catatonia and post-partum depres- 
sion were relatively rare. Suicide was also thought to be quite rare now. 
Both the Shanghai Mental Hospital and the psychiatric ward of the 
Third Hospital in Peking reported that the most common age of onset 
of mental illness was from 20 to 30 years old. This corroborates the find- 



298 MEDICINE AND PUBLIC HEALTH 

ings in the 1930's as well when, in one study of mental illness, 40% of 
the patients' onset of illness was from 20 to 30 years. 3f 

In a study done in the late 1950's involving a group of 2,000 schizo- 
phrenics, it was found that 50% of the patients were between the ages 
of 21 and 30; only 1.3% were under 15 years of age; and over 7% were 
more than 40 years of age. 4 Over 46% of the schizophrenics were para- 
noid, 24% were "unclassified", 15% were suffering from hebephrenia 
and 11% were suffering from catatonia. 4 

The Personnel 

Before the Cultural Revolution most psychiatrists attended 
medical school for five years and during the fifth year interned in a 
department of psychiatry in a teaching hospital specializing in psychia- 
try, internal medicine, and neurology. They would then remain in a 
psychiatric department of a hospital, learning the field further through 
doing "practical work," making rounds, attending lectures and treating 
patients under the supervision of residents. A psychiatrist was con- 
sidered trained when the senior doctors in his department felt he was 
adequately trained; there was no examination or fixed period of train- 
ing. As medical schools have just reopened since the Cultural Revolu- 
tion, a new pattern has yet to be established. The percentage of women 
in psychiatry at the present time is thought to be over 50%. 

Nurses are trained under the same basic principles. Again before the 
Cultural Revolution they graduated from nursing school, during which 
they would have some psychiatric studies. They then had on the job 
training in the psychiatric ward to which they were assigned, which in- 
cluded practical work and some lectures. 

The works of Freud are not and have not been used in the study of 
psychiatry since 1949; the works of Pavlov, however, have been studied, 
particularly during the period of Russian influence, but our hosts told 
us that without "considerable environmental and class struggle" the ap- 
plication of Pavlov's theories will not be effective. 

Hospital Life 

At the Shanghai Mental Hospital a Mao Tse-tung study 
class meets every afternoon for two weeks from 2 o'clock to three thirty. 
Eleven patients dressed in brown uniforms sit around a table with one 
member of the People's Liberation Army and one member of a Mao 
Tse-tung Propaganda team who works in the hospital and takes part in 
the study class when he is free. One health worker is also present who 
is in charge of the patients' study group in this ward. They are study- 
ing the third Constantly-Read Article, "The Foolish Old Man Who 



MENTAL DISEASES 299 

Removed the Mountains.'' One patient tells the content of the parable, 
the story of an old man who had a mountain on his property and 
wanted it removed. He and his sons started to remove it with shovels 
and his neighbors scoffed at him. But he insisted that if his sons and 
his sons' sons worked to remove the mountain, it could be done. He 
explained that they should all learn the spirit of the parable and put 
it into practice in order to strengthen their will and conquer their ill- 
ness. Two of the patients sitting around the table are wearing red 
arm bands since they are on duty and their main task is to propagan- 
dize Mao's thought when new patients come into their ward. They tell 
new patients their experiences and help them get used to being on the 
ward. The patients who are on duty rotate so that everyone in the 
ward has a chance. 

Patients live two, four, eight or sixteen to a room, depending on the 
severity of the condition. There were a few rooms with a single patient 
and some of these were locked. The rooms are furnished very simply 
with beds, bureaus, and posters or slogans on the walls. The patients 
make their beds and sweep the floors with the help of the health 
workers. The daily schedule was up on one wall and was as follows: 



5:00- 5:30 A.M. 


Get up and make beds 


5:30- 6:00 


Breakfast 


6:00- 6:30 


Occupational therapy 


6:30- 7:00 


Military training (Fridays) 


7:30- 8:30 


Study Chairman Mao's works 


8:30-10:00 


Heart-to-heart talks (Monday, 




Wednesday, Friday) 


8:30-10:00 


Study class (Tuesday, Thursday 




Saturday) 


10:00-10:30 


Treatment 


10:30-11:30 


Lunch, free time 


12:00- 1:30 


Nap 


1:30- 2:00 


News 


2:30- 3:30 


Study class 


3:30- 4:15 


Physical activities (Monday, 




Wednesday, Friday) 


3:30- 6:30 


Visits from relatives (Tuesday, 




Thursday, Saturday) 


4:30 


Supper 


Evening 


Television 


9:30 


Bed 



Exhortatory messages were on the walls as well. Lin Piao's quotation 
read: "Read Chairman Mao's Works. Listen to Chairman Mao. Work 



300 MEDICINE AND PUBLIC HEALTH 

according to Chairman Mao's teachings. Act as Good Fighters for 
Chairman Mao." In another room of the Shanghai Mental Hospital a 
poster was on the wall, entitled, "How to Prevent Disease Relapse." 
The first two items read: 

1. Mental Disease is curable. 

2. Being a psychiatric patient, you still have to study Chairman 
Mao's works hard. 

The third point dealt with acupuncture and the fourth point read: 
"Sometimes you will have symptoms. Don't worry. If you get treatment 
right away, relapse can be avoided." 

In the patients' activity room they were playing Chinese chess, ping- 
pong, doing occupational therapy, and reading small comic-like books. 
There was a loudspeaker playing a lively song from a modern revolu- 
tionary opera. Slogans hung across the room: "Hold High the Red Ban- 
ner of Mao's Thought" and "Warmly Celebrate the Founding of the 
People's Republic of China." Those patients who are doing particularly 
well in their "struggle against their illness" have short essays written 
about them by the doctor and other patients and these are posted on 
the wall. Also posted is the list of the patients who are paired together 
to help each other, the sicker with the healthier. 

The average length of hospitalization currently in the Shanghai 
Mental Hospital is 70 days. The doctors felt that the relapse rate of 
schizophrenia before the Cultural Revolution was a problem— 40% of 
the patients were likely to have two or three admissions. Currently they 
are emphasizing reeducation "right before the patients are discharged 
on how to deal with the environment and contradictions within the en- 
vironment." They have also been conducting follow-up studies on re- 
lapse and have found in one ward which was studied for one year that 
18.3% of the patients suffered from relapse. Relapse was interpreted to 
mean the need for re-admission or outpatient treatment. In a one year's 
study of another ward they studied 37 cases and found one case of re- 
lapse; this case was treated by treatment in the home and in the out- 
patient department. They felt that the most important factor against a 
higli relapse rate is the Mao Study Class "to arm them with Mao's 
thoughts to better deal with the environment." 

Acupuncture is considered a major method of treatment in the lower- 
ing of the relapse rate. The doctors at the Shanghai Mental Hospital 
have divided the criteria for success of acupuncture treatment into four 
levels: 1) cure— disappearance of symptoms with the patient "managing 
everything by his own mentality;" 2) much improved— disappearance of 
symptoms and the patient "mostly managing by his own mentality;" 3) 
improved— with some remaining symptoms; and, 4) unimproved. They 
have recently studied 157 cases of schizophrenia for one year and found 



MENTAL DISEASES 301 

that 74.3% of the patients were cured and much improved. They fur- 
ther found that 97.4% fell in the first three categories, that is, cured, 
much improved and improved. Without acupuncture treatment they 
find a 70% relapse rate. 

Because of the recent disclosures of the political use of psychiatry in 
the Soviet Union, the process of psychiatric hospitalization seemed an 
important one to understand. The doctors at the Psychiatric Ward of 
the Third Hospital in Peking say that hospitalization is nearly always 
through persuasion, through the persuasion of relatives, friends, and 
colleagues at work. Admission to the hospital is generally a joint effort 
by the family and the authorities of the unit in which the patient 
works and usually they all agree on the need for hospitalization. Occa- 
sionally commitment is by force but this was thought to be exceptional. 

After admission the patient needs to be persuaded by the personnel 
to remain and receive treatment. The technique of welcoming new pa- 
tients by old patients and the old patients helping the new patients to 
adjust was considered important in this beginning phase of hospitaliza- 
tion. As the patient recovers slightly he sometimes must be persuaded to 
stay in order to get a thorough improvement. The doctors maintain 
that the patients never leave the hospital against the advice of the physi- 
cian and feel this is because the physicians obtain the cooperation of 
the members of the Revolutionary Committee where the patients work 
and of the patient's family. They stressed that the patient respects the 
opinions of the authorities where he works and if the doctor, the pa- 
tient's family, and the members of the Revolutionary Committee all 
agree, the patient is likely to abide by their suggestions. 

Summary 

Currently the treatment of mental illness in the People's 
Republic of China is a process involving multiple techniques: tradi- 
tional and Western medicine, group and individual relationships, pro- 
fessional and non-professional help, mutual help and self-reliance, and 
in-hospital and community involvement. Since the Cultural Revolution 
new models of organizing patients in mental hospitals in order to 
"raise the patient's initiative to fight his disease" are being extensively 
tried. The writing and thinking of Mao Tse-tung underlies all of these 
efforts. 

Several basic characteristics of Chinese society are critical to the han- 
dling of mental health: 

1. The society is an extraordinarily cohesive one and the effects of 
this cohesion have not begun to be explored with regard to the 
incidence and treatment of mental illness. 



302 MEDICINE AND PUBLIC HEALTH 

2. The organization of the society into small groups in which mu- 
tual help and local participation are emphasized must be seen 
both as an effort at preventive mental health and as an adjunct 
to the treatment of mental patients. 

3. The belief in the malleability and perfectability of man 
through "education and re-education" is the foundation on 
which many of the new techniques such as Mao Tse-tung study 
groups are based. 

4. Although the Chinese are attempting to fashion their own 
brand of mental health services through using their social struc- 
ture and their traditional medicine, they incorporate Western 
techniques, such as drug therapy, when they feel they are useful. 

Throughout the Chinese medical care system, as well as in other fac- 
ets of life, their pragmatism and willingness to experiment are highly 
evident. Thus, the treatment of mental illness in China is likely to be a 
changing picture which we in the West would do well to observe. 



MENTAL DISEASES 303 

REFERENCES 

1. Veith, I.: "Psychiatric Thought in Chinese Medicine." /. Hist. Med. &.• Allied Sr 
10: 261-268, July 1955. 

2. Veith, I.: "The Supernatural in Far Eastern Concepts of Mental Disease." Bull, 
of the Hist, of Med. 37: 139-155, March-April 1963. 

3. Lamson, H. D.: Social Pathology in China. The Commercial Press, Ltd., Shanghai. 
1935, (a) pp. 415-416; (b) p. 416; (c) p. 410; (rf) pp. 109-112; (e) p. 366; (/) p. 411. 

4. Cerny, J.: "Chinese Psychiatry." International J. Psychiatry 1: 229-238, April 1965. 

5. Hatem, G.: "With Mao Tse-tung's Thought as the Compass For Action in the 
Control of Venereal Diseases in China." China's Medicine 1: 52-68, Octoher 1966. 

6. Lyman, R. S., Maeker, V., and Liang, P., editors: Neuropsychiatry in China. 
Henri Vetch, Peking, 1939, (a) p. 234; (b) p. 233. 



INDEX 



Abbott, J. C, 239 

Abdominal pain relieved by acupunc- 
ture, 87 
Abortion, 202, 203 

absence of legal or moral objections 

to, 207 
availability of, 207 
estimated rate of, 220 
techniques, improvement in, 204 
Actinomycin K., 269, 272 
Academia Sinica, 99, 175 
Academy of Medical Sciences, The, 

173-190 
Academy of Medical Sciences, Chinese, 
list of Institutes and hospitals under 
the, 189-190 
Academy of Traditional Medicine, 145 
Accounting in Medical care, and allo- 
cation of funds, 150 
Achievement and family and societal 

values, 42 
Achievements, pharmacological, 97-100 
Acupuncture, xii, 60, 63-92, 93, 178, 210 
abdominal pain, and, 87 
analgesic effect of, 84 
anesthesia, 17, 60, 64, 76, 80, 88-89, 
106, 185 

advantages of, 81, 82-83 
brain, role of, in, 84 
development of, 80-81, 185, 186 
illustrated, 81 
inexpensive, 82 
prerequisites for, 81 
success ratios tabulated, 89 
superior to conventional an- 
esthetics?, 82 
autonomic nervous system and, 76 
barefoot doctors, and the, 149 
barefoot doctors, used by, 15, 16 
blindness treated by, 85 



blood releasing needles, 74 

cancer, in, 272 

cerebral cortex involvement in, 84 

challenged at beginning of twen- 
tieth century, 65 

Chinese term for, 63 

claims confirmed, 63 

complex subject, a, 64 

current status of, 76-89 

defined, 63 

description of some applications, 63 

developments in China and new, 
76-89 

dismissed by Western medicine, 63 

early explanation of, 6 

effects of, reported, 16 

effects of, various, 72 

electrical activation of needles in 
anesthesia, 81 

English textbooks on, 89-90 

equipment not expensive, 15 

eye diseases, in, illustrated, 86 

500-800 points of, 69 

France, in, 66 

general ailments, in, 85-88 

general strengthening by, 73 

goiter treatment, in, 87 

headaches, in, 71 

hemiplegia, in, 82 

hepatitis, in, 87 

history of, 65 

humoral factors in, 85 

importance of te ch'i in, 82 

induction period in, 82 

infantile paralysis, in, 88 

influenza, and, 88 

internal harmony and, 6, 7 

insertion techniques, 74 

International conference on, 78 

International Society of, 66 

irrational in Western eyes, 90 



305 



306 



Japan, in, 65 

Japanese charts of, 69 

Korea, in, 65 

law of five elements in, 68 

leprosy, and, 247 

medical courses, taught in, 17 

mental diseases, in, 292, 293 

mental illness, in, 296, 300 

meridian lines, and 65 

modern anatomical textbooks and, 

77 
moxibustion and, 65 
needles and techniques, 74 
needles illustrated, 75 
neural pathway in, 78 
neurology and, 85 
not regarded as a cure-all, 85 
pain suppression by, 84 
paralysis, in treatment of, 86 
Paris hospitals' consultations, 66 
percent of rural cases treated by, 16 
physiological changes caused by, 

83-84 
plastic ear model illustrated, 80 
plastic mannikin illustrated, 79 
points 

European numbers system, 69, 
71 

meridians and the, 69-74 

five elements, 68-69 
post operative anal pain, in, 87-88 
prohibited areas, 74 
pulse diagnosis in, 73-74 
regulatory effect of, 84 
research into, 63 

theoretical aspects of, 182 
rhyme regarding points for, 72 
rules of; 71-73 

summarized, 73 
"secret points" of, 69 
special wards in hospitals for, 10 
standard textbook on, a, 77 
sterile environment used in, 76 
stimulation therapy, as, 78 
structure of spots anatomical, 82 
superior to Western treatment in 

hepatitis experiment, 87 
techniques and needles, 74 
therapeutic efficacy of, 85-89 



tonifying effect in, 72 

tonsillectomy and, 64 

tranquilizing effect in, 72 

tuberculosis, in, 244 

United States, in the, 66 

Vietnam, in, 65 

Western re-evaluation of, needed, 

64 
worker doctor, by, 161 
worldwide spread of, 65-66 
Addison's disease, 99 
Administration and organization of 

health care, 111-190 
Advantages of anesthesia by acupunc- 
ture, 82-83 
Aedes logoi, 254 
Aflatoxin, 230, 231 

Africa, Chinese medical teams in, 59 
Aging, death and illness and the fam- 
ily, 35-37 
Agricultural Development, National 

Programme for, 242 
Agricultural productivity, pharmacolog- 
ical emphasis on, 94 
Agriculture 

capital formation, and, 144 
basis of economic growth, as a. 148 
progress in, 217 
Twelve-Year Plan, and the, 144 
Ailments, general 
Aird, John, 48 
Albert-Einstein College of Medicine, 

New York, xiv 
Alcohol, 96 
Alcohol consumption and cancer, 228- 

229 
Alexander, W. D„ 237 
Allan, T. 61 

Allium Tuberosum Roxb., 101 
American medical scientists visiting 

China, 18 
American physicians and scientists visit 

China in 1971, xii 
Anal region pain postoperative, acu- 
puncture relieving, 87-88 
Analgesia, acupuncture and, 82 
Analysis of cancer data, 270 
Anastomosis, venous, 57 

restorative surgery, in, 57 
Ancylostoma duodenale, 259 



INDEX 



307 



Ancylostomiasis, xv, 97, 216, 242, 259-260 
diagnosis, 259 
symptoms, 259 
treatment, 259-260 

Anecdote on urban physician living with 
barefoot doctor, 159 

Anemia, iron deficiency type, 232 

Anesthesia, acupuncture, by 
see Acupuncture 

Anesthesia maintenance by acupuncture, 
82 

Anesthesic agents, early use of, 54, 55 

Anesthetics, conventional, acupuncture 
anesthesia superior to?, 82 

Animals 

encephalitis transmission, in, 248 
medicinal, breeding programs, 105 

Anopheles hyrcanus, 248 

Anopheles lesteri, 252 

Anopheles sinensis, 248, 252, 254 

Anthropology, medical, 14 

Antibacterial drugs, 98-99 

Antibiotic factories, 100 

Antibiotics in use in China listed, 100 

Anticancer drugs, 94 

Anticancer shock brigade model, xv 

Anti-disaster struggle, the, 124 

Anti -elitism, 177 

Anti-foreignism in early 1900s, 55 

Anti -professional more in medicine, 44 

Anti-professionalism in research policy, 
173 

Anti-social behavior not tolerated, 288 

Anti-traditional aspects of Cultural Rev- 
olution, 15 

Anti-tumor medicine, xv 

Apprentice method of training tradi- 
tional practitioners, 11 

Ariel, I. M., 283 

Armed forces, health care, and public 
and private personnel, 132 

Army personnel provide medical services 
to liberated villages, 155 

Arnold, M. B.. 237 

Artemisia vulgaris, 63. 103 

Arthritis, 121 

Yscariasis of bile duct, 17 

combined treatment in, 17 

Aspergillus flavus, 230, 231 

Assistant doctors, statistics on, 158 



Aster tartaricus, medicinal, illustrated, 
105 

Asthma, 178 

Autonomic nervous system and acu- 
puncture, 76 

Autopsies, first permission for, 55 

Auxiliary health workers, 143 

Aykroyd, W. A., 236 

B 

Bacteriology, surgical, studies at Peking. 

56 
Bag, contents of barefoot and worker 

doctors, 160 
"Barefoot doctor," the, xiv, 15, 45, 59, 
151, 209, 265 
acupuncture anesthesia and, 82 
Barefoot Doctor Handbook, 160 
excerpt from Table of Contents 
of, 167-169 
birth control, and, 205 
duties of, 160 
forerunner of, the, 147 
heroes, the, 17 
income of, annual, 161 
standard items carried by, 169-171 
support for the, 149 
trained by urban physicians, 159 
training curriculum for, 59 
training of, 166-167 
Bart, Pauline B., 41, 50 
Basic-level health organization at Com- 
mune, illustrated, 146 
Basic-level public health organizations. 

133 
Bell, Robert B., 50 
Benicasa hispada, 102 
Bennett, F. J., 47 

Benzene hexachloride in mosquito elim- 
ination, 252, 254 
Bexhenium salt of gallic acid, Ancylos- 
tomiasis, in, 259 
Berg, J. W., 237 
Berger, Peter, 50 
Betel nut, 96 
Bethune, Norman, 58 
Bhatia, B. B., 237 
Biochemistry, Institute of, 99 
Biomedical research, ix 

coordination and organization, xiv 
Birth and death, medical presence sat- 
isfactory at, 193 



308 



INDEX 



Birth and death rates and economic 

problems, 193 
Birth control 

contraceptive supply inadequate, 

205 
data and Red Guard doctors, 162 
economic crisis and recovery, and, 

203, 204 
encouragement of, 219 
methods available listed, 207 
mobile medical teams disseminating 

information on, 204, 205 
necessity for, 201-202 
official statement on, 202 
organizations involved in dissem- 
inating information on, 202 
pills distributed by barefoot doc- 
tors, 205 
propaganda, reactions and results, 

205-208 
Research Committee, 202 
Birth rate 

current crude estimated, 208 
declined in cities, 162 
diseases, epidemic, and, 200 
downward trend in 1960s possible, 

206 
natural disasters affecting, 200 
patriotic considerations and, 206 
Blindness, acupuncture and, 85 
Blitzkrieg public health war in 1953, 

119 
Blood pressure in acupuncture anes- 
thesia, 83 
Blood releasing needles in acupuncture, 

74 
Bloomfield, Constance, 51 
Board members of Academy of Sciences, 

175 
Boll, Eleanor, 49 
Bong Han, Kim, 78 
Border quarantine regulations, 123 
Bossard. fames, 49 
Bowers, John Z., xii, 53, 61 
Boym, Michael, 96 
Brain 

its role in acupuncture anesthesia, 

84 
surgery standard in China, 59 
Bross, I. J., 238 
lirucea javanica L., 97 



Bubonic plague, 120, 123 
Buck, J. L., 239 
Buell, P., 238 

Buffer zones between residential and in- 
dustrial areas, 133 
Burch, Thomas, 37, 50 
Bureau of the Census, U.S., 212 
Burns, 17 

combined treatment in, 17 
team treatment of, 58 
Burton, Ernest De Witt, 55 
Butler, W. H. 239 
Buttrick, Wallace, 56 

C 

Calcium and fluoride levels and goiter 

225 
Camphor, 96 
Cancer, 108, 178 

acupuncture in, 272 

agencies engaged in research, list of, 

266 
alcohol consumption and, 228, 229 
analysis of data, 270 
anti-cancer campaign, 270 
anticancer drugs, 94 
anti-tumor medicine, traditional, 

269 
brain metastasis, 279 
"cancer in China" papers, 1929, 266 
cancer registration, 271 
Cancer Research Institute, 185 
carcinogens and diet, and, 227 
carcinoma distribution tabulated 

267-268 
cervical 

five year survival rates tabu- 
lated, 274, 275 
radiation results tabulated, 274 
challenge of eliminating cancer in 

China, 227 
chemotherapeutic agents, method 

of administration, table of, 280 
chemotherapy, 279 
chorioadenoma destruens, 279 
choriocarcinoma, 279 
colon and rectum, of, 229 
colonic, schistosomiasis, and, 250 
Committee for Cancer Research, 

270,271 
common sites of, 269 



INDEX 



309 



Cancer (cont'd) 

diagnosis, 279 

education, cancer, 271 

elimination of, xv, xvi 

endometrial, fat consumption and, 
228 

epidemiologic studies, 267-268 

esophageal, 228, 272 

experiment animals, in, 230, 231 

fifty percent cure rate with herbal 
medicine, 277 

five-year survival rates tabulated, 
274, 275 

"Give Cancer its Deathblow" cam- 
paign, 270 

hepatoma, 227 

high rate in Bern and Lebanon, 226 

Human Cancer Hospital, 267 

increased incidence reported, 227, 
228 

International Cancer Congress, 
Eighth, 267 

iron deficiency and, 229 

liver, of the, 230 

mass examinations for cervix uteri 
cancer, 271 

morphologic studies, 267-268 

mortality rate in relation to clinical 
staging, 280 

nasopharynx, of the, 230 

National Tumor Conference, 270 

nutrition and, 227-231 

organization of research, 265-269 

osteosarcoma, 269 

preventive programs, 265-268 

primary sites tabulated, 281-282 

protein deficiency, 227 

radiation therapy, 272 

registry program, xvi 

research organization, 265-268 

schistosomiasis and, 230 

screening program, 270-271 

squamous-cell carcinoma of esopha- 
gus, survival rate tabulated, 277 

stomach, of the, 229 

surgical case fatality tabulated, 
275-276 

survey, 270-271 

therapy, 272-277 

thyroid, of the, 226 

traditional drugs in therapy, 272 



treatment results tabulated, 273 
Tumor Institute in Academy of 

Medical Sciences, 267 
tumor research organizations listed, 

278 
tumor treatment tabulated 273 
tumors, experimental, 268-269 
uterine cancer incidence, 228 
Candidates for medical schools chosen 

by fellow workers, 163 
Canton Ophthalmic Hospital, 54 
Capabilities, indigenous, in research, 173 
Cardiac transplants, early reference to, 

54 
Cardiovascular drugs, 98 
Carnegie Endowment for International 

Peace, 56 
Carthamus tinctorius, 105 
Casella, A., 236 
Castration, 54 
Cataract, 55 

Catering in communes and factories, 30 
Causation and prevention of disease in 

China, 23 
Carcinoma 

See Cancer 
Census of 1953, The, 194-195 
Central Institute of Medical Research, 

177 
Cerebral cortex changes caused by acu- 
puncture, 84 
Cerny, J., 303 
Cessation of professional publications. 

xii 
Chai-ssu, Huang, 148 
Chamberlin, Thomas Crowder, 55 
Chang, C, 91, 261 
Chang, C. F., 283 
Chang Chung-Ching, 6 
Chang, H. L., 262 
Chang, M. H., 261 
Chang, S. Y„ 285 
Chang. T., 91 
Chang, W., 286 
Chang, Y. L., 286 
Chao, C. C, 91 
Chao, C. Y., 109 
Chao, Y. C, 283, 284 
Chao-chih, Lin, 180 
Chastity considered virtuous, 206 



;io 



INDEX 



Chemical synthesis, 94 
Chen, C, 262 
Chen, C. H., 263 
Cheng, C. L., 263 
Cheng, C. Y., 187 
Chen chiu 

see also Acupuncture 
Chen, H. C, 284 
Chen, H. T., 263 
Chen, H. Y., 262 
Chen, I., 91 

Chen, James Y. P., xiii, 63-92, 93-110 
Chen, Jerome, 152 
Chen, K. H., 283 
Chen, K. L,. 261 
Chen, M. C, 262 
Ch'en Pang-hsien, 21 
Chen, W. H., 263 
Chen, W. Y., 261 
Chi, J. Y., 109 
Ch'i, the energy of life, 66 
Chi-chen, Shen, 180 
Chiang, Y. L., 109 
Chiange, C. H., 263 
Chiao-chih, Lin, 185 
Chia-ssu, Huang, 180, 185 

President of Chinese Academy of 
Medical Sciences, 180 
Chia-yu, Hsu, 159 
Chien, C. H., 261 
Chien, H. C, 269, 284 
Chih-ch'iang, Chang, 181 
Childbearing incentives, 33 
Childbirth, 33-35 

hazards in pre-Liberation China, 
216 
Childcare, 33-35 

Model communes and, 34 

urban areas, in, 34-35 
Child training learned in school, 41 
"Children belong to the nation," 33 
Chin, Chin, 91 
Chin, H. C, 286 
Chin, K. C, 109 
Chin, K. Y., 283 
Chin, L. C, 263 
Chin, Y. C, 109 

China and the scientific revolution, 7 
China last country to adopt western 

surgery, 53 
China Medical Board, The, 155 



China Medical College, 156 
China Physiology Society, 180 
China, the Revolution Continued, 26 
China the "sick man of East Asia," 113 
China's Health Problems, 153 
China's Medicine, 161 
Chinese Academy of Medical Sciences, 
the, xiv, 148, 174, 179, 180, 181-182, 
222, 278 
Chinese Academy of Sciences, The, 94 

departments listed, 175 
Chinese- American relations, 18 
Chinese Art of Healing, The, 89 
"Chinese diseases," 25 
Chinese family 
culture, its, 23 

examination of the role of, 23 
Chinese Family in Communist Transi- 
tion, The, 26 
Chinese Journal of Nutrition, 217 
Chinese materia medica, historic review 

of, xiii 
Chinese Medical Association, 89, 154, 

157,278,288 
Chinese Medical Journal, the, 93, 217 
research articles disappeared from, 
13 
Chinese Medicine Research Institute, 

Peking, 11, 17 
Chinese Medicine Through the Ages, 

1-110 
Chinese National Bibliography, Peking, 

233 
Chinese People's Republic 
health problems and, xii 
knowledge of medical scene in, lim- 
ited, xii 
medical and public health activities 

in, ix 
Ministry of Health of, xii 
population of, xi 
Chinese-Western collaboration in acu- 
puncture anesthesia, 80 
Ching Lo, 69 
Clung, Mai, 69 
Ching, P. H., 285 
Chinglo, 83 
Chiu, C. M., 284 
Chiu, F. H., 261 
Chiu, H, 187 
Chlorpromazine in mental illness, 295 



INDEX 



311 



Cholangiocarcinoma, parsitic infection 
and, 230 

Cholera, 120, 123, 216 

prevention of, the, 118 
wiped out, 242 

Chou dynasty, the, 215 

Chou, H. C, 109, 262, 263 

Chow, Bacon F., xv, 215-239 

Chow, Chuang, 221 

Chrysanthemum indicum L, 98, 105 

Chu, F. T., 261 

Chu, H. H., 262 

Chu Hsi, quoted, 8 

Chu, Lien 78, 91 

Chu-yuan, Cheng, 179 

Chung, C. Y„ 261 

Chung, H. L., 109, 263, 264 

Chung-i, 8 

surgery and, 53 

Chunhsing production brigade, The, 
150 

Ciaudo, D., 237 

Cirrhosis, liver, schistosomiasis in, 249, 
250 

City personnel in rural medical services, 
147 

Classification of illnesses, Chinese, 25 

Classified Materia Medica, 95 

Clements, F. W. 237 

Clerodendron trichotomum T., 98 

Clinics, Affiliated, 142 

Clinics management regulations, 126 

Clonorchiasis, xv, 255-257 
blood picture in, 256 
chemotherapy unsatisfactory, 257 
incidence, 256 
snails as hosts of, 256 
symptoms of, 256 

Clonorchis sinensis, 256 

C Ion orchis sinensis, cholangiocarcinoma 
and, 230 

Coble, Y. D., 237 

Collections of Laws and Decrees of the 
Central People's Government and Col- 
lection of Laws and Regulations of the 
People's Republic of China, xiv, 114 

Colleges and hospitals, missionary- 
founded, 12 

Colleges for teaching traditional medi- 
cine, 10 

Colon, cancer of, incidence, 229 



Columbia Medical Center, 226-227 
Combined treatment— modern and tra- 
ditional, 17 
Communes, initiation of, xi 
Communes rural health centers, and 14 
Communicable diseases and the family 

unit, 214 
Communication, progress in, 217 
Communist Chinese, arduous existence 

prior to 1949, 113 
Communist Chinese law, xiv 
Communist Party intention to promote 

public health, 113 
Communist take over and suggested 

birth rate increase, 205 
Community and disease prevention the, 

43 
Community as patient, the, 43-44 
Community ethos and mental illness, 293 
Community influence over medical care, 

45 
Community as a practitioner, the, 44 
"Companions life family," the, 28 
Confucian China, family unit in, the, 31 
Confucian doctor, the, 7, 8 
Confucian doctrine and the human body, 

53 
Confucianism and the local culture, 41 
Connective tissue looser at acupuncture 

points, 78 
Conney, A. H., 238 

Conservation of medicinal materials, 136 
Construction projects, conditions at, 210 
Contraception, 201 

Contraceptive techniques adoption, 27 
Contraceptives, inadequate supply of, 

205 
Contraceptives, oral, availability of, 207 
Control of medicinal materials, 134-135 
Controversy over traditional medicine, 8 
Conway, W. D., 239 
Cooperation, international in bio-inedi- 

cal research, ix 
Copeland, D. H., 239 
Coptis chinesis F., 98-99 
Coptis tecta, 96 
Corn flour used in antibiotic production 

100 
Corn silk, medicinal, 103 
Coronary heart disease, 227 
Corpses, rules for dissecting, 136 



312 



INDEX 



Corydalis ambigua, 96, 98 

Cosmological ideas and classic medical 
tests, 5 

County hospitals, departments of, 144 

Course lengths in medical education, 127 

Cramer, J. W., 238 

Cranmer-Bying, J. L., 61 

Creative cycle of five forces, 67 

Cretinism incidence, 226 

Criteria for admission to higher educa- 
tion, 163, 164 

Criticism of educational system, 163 

Croizier, Ralph C, xiii, 3-21, 61, 91, 

93, 109, 153, 154, 157, 172 
Crook, Isabel and David, 26 
Culex pallens, 248 

Culex pipiens, 248 

Cultivation of medicinal materials, 135, 
136 

Cultural determinants and diseases, 23 

Cultural heritage of traditional medi- 
cine, 8 

Cultural isolation of China, and sur- 
gery, 53 

Cultural nationalism and medicine, 12, 
157 

Cultural Revolution, The, xi, 12, 35, 45, 

94, 159, 163. 180, 241, 291, 292, 301, 
148 

launched in 1966, xi 

impact of, xii 
medical education discontinued 

during, 158 
medical world, and the, 15 
Culture and the family, 25 
Culture, Education and Health, De- 
partment of, 145 
Culture, family as a repository, 41-42 
Curative and preventive techniques 

learned by auxiliaries, 143 
Cutaneo-visceral reflex, 78 

I) 

Data sources on family life and popu- 
lation processes, 26-28 
Datura, 54 
Datura alba, 96 
Dawson, E. A., 238 
Day care centers, 34 
Deaf-mutism, acupuncture and, 85 



Death, aging and illness and the fam- 
ily, 35-37 
Death rate 

downward trend, start of, 210 

estimating the, 200 

in 1934, 200 

published evaluation of, 208 
Decentralization of health care respon- 
sibility, 145 
Deer, Sika variety, illustrated, 107 
Deficiencies, nutritional, 217 
Deficiency states have disappeared, 218 
Delange, F., 237 
de Morant, George Soulie, 66 
Dentists, statistics on, 158 
Departments of Chinese Academy of 

Medical Sciences, list of, 181 
Deputy Minister of Health, charge 

against, 13 
Dermatology and Venereology Institute 

of, The, 179 
Description of the Empire of China, A, 

96 
Destructive cycle of five forces, 67 
Deviation, ideological, 13 
Diagnosis 

physician's observation in, 7 

pulse, 73-74 

pulse lore in, 7 
Diagnostics, 7 
Diaminodiphenylsulphone in leprosy 

treatment, 247 
Diarrhea, 17 

Diet, Chinese, general, 231-233 
Diet and Cancer 

see also Cancer, Nutrition 
Diet 

nutrition, 41 

pre-liberation China in, 216 

stomach cancer, 229 

Dimond, E. G., 91, 109, 172, 185, 
187.227,238, 264,283 
Dioscorea japonica, 105 
Disasters, natural, efforts against effects 

of, 124 
Diseases 

causation in China, 23 

cultural determinents, 23 

deficiency diseases eliminated, 218 

endocrine and metabolic, 222 

folk views of tolerated, 42 



INDEX 



313 



Diseases (cont'd) 

germ theory and the family, 23 

infectious and parasitic, xv, 241-264 

local definitions of, 43-44 

occupational, 122 

prevention and the community, 43 

relief from, peace and, ix 

result of imbalance of forces, 66 

ten discussed, 242-260 

"trachoma China's most prevalent 
disease," 247 

viral, 108 

"wiping out the", 141 
Dissection of corpses, laws on, 136 
Doctor of medicine, definition of, 154 
Doctor— population ratio, 155, 156, 162 
Doctors, barefoot 

see "Barefoot doctors" 
Doctors, dentists and nurses, M.S. Sta- 
tistics, 1970, 158 
"Doctors to the countryside," said 

Mao Tse-tung, 15 
"Doctors were true scholars", 200 
Doctrinal goals, problems implementing, 

174-176 
Doctrine, a, for research, 173-174 
Doctrine of the five elements, 67-68 
"Downward" transfer of medical in- 
tellectuals, 177 
Drinking water, safety of, 124 
Dropsy, 178 
Drug therapy, 6, 7 
Drugs 

antibacterial, 98-99 

biologicals, 99-100 

cardiovascular, 98 

classified in Compendium of Ma- 
teria Medica, 95 

herbal, xiv 

parasitic diseases against, 97-98 

synthetic, xiv, 97-104 

vegetable origin, of, 96 
du Halde, 96 
Dungal, N., 238 
Dunn, J. E., 238 
Dwarfism, schistosomiasis, in, 250 
Dynamics, population, 193-213 
Dysentery, 216 



Early marriage, 203, 204 
Earthworms, medicinal, 103 



"East is Red" Hospital, Shanghai, 159 
Ecological matters and government di- 
rectives, 132-133 
Economic crisis of 1959, 203 
Economic functions of the family, 29 
Economic growth, agriculture as a bisis 

for, 148 
Economic problems and the birth and 

death rates, 193 
Economic recovery and birth control 

propaganda, 204 
Edmondson, H. A., 238 
Education, 33-35 

Academy of Medical Sciences, The, 

173-190 
"barefoot doctor", of the, 166 
cancer education, 271 
clinical training courses, 165 
criticism of old educational system, 

163 
grades not used in, 166 
higher education, changes in, 163 
medical 

curriculum, 165, 233 
medical, directives on, 126-127 
medical, discontinued during Cul- 
tural Revolution, 158 
medical, 

intentions in, 1 1 
Party directives, and, 1 1 
"Practicing while learning," 210 
secondary emphasis on, 209 
schools, 164-166 
training shortened, 165 
no attrition for academic reasons, 

166 
nutritional, 218, 233-234 
political, 30 
progress in, 217 
public health, in, 126 
"Revolutionary Committees, and, 

162. 163 
strides made in, 206 
"three-in-one principle", the, 166 
Educational system and achievement 

motivation, 42 
Eisenstadt, Sergei, 50 
Electropotentiometers used in meridians 

research, 78 
Elements, the five, tabulated, 70 
Eliot, Charles W., 55, 61 



314 



INDEX 



Elephantiasis, filariasis, in, 254 

Elitism, assault on, 15 

Elsholtzia cristata, 96 

Emergency Medical Services Training 

Schools, 155 
Emergency operations, acupuncture an- 
esthesia in, 83 
Emergency procedures, barefoot doctors, 

and, 59 
Emigration from China, 27-28 
Empirical base of traditional medicine, 

154 
Empiricism and traditional medicine, 7 
Encephalitis, xv, 99 
Encephalitis, Japanese B, 248-249 

description of symptoms of, 248-249 
diagnosis, 249 

mosquito breeding cycle, and the, 
248 
Endemic areas, goiter, 222 
Endemic diseases and the family as a 

unit, 24 
Endometrial cancer and fat consump- 
tion, 228 
English, J. T., 47 

English textbooks on acupuncture, 89-90 
En-lai, Chou, 202 

birth control, advocating, 202 
Environmental factors in pathology, 6 
Environmental hygiene, 8 
Ephedra vulgaris, 96 
Ephedrin, 106 
Epidemic diseases affecting birth rate, 

200 
Epidemic of pneumonic plague in 

Manchuria, 55 
Epidemic Prevention Stations, The, 142 
Epidemiology, data on, 27 
Epidemiology Research Institute, 185 
Equilibrium and natural order of hu- 
man society, 6 
Ermans, A. M., 237 
Escher, G., 238 
Esophageal Cancer 

conference on, 272 
incidence, 228 

survival rate tabulated, 277 
Etiology 

role of family in, 23 
family behavior, and, 46 
Encomia ulmoides, 96 



Eunuchs and the Imperial Court, 54 
"European diseases" in China, 25 
Every Fifth Child: The Population of 

China, xv 
Experience, exchange of Red Guard 

doctors, by, 167 
Experimental Medicine Institute, 185 
Ex-urban medical resources, 4 
Eye defects, acupuncture treatment in, 

85 
Eye diseases, acupuncture in treatment 

of, illustrated, 86 



Faber, Kund, 154, 172 
Facilities, public health, network of, 125 
Factory jobs sex-linked, 40 
Factory worker and land worker, in- 
come contrasted, 30 
Family, the 

culture, as a repository of, 25, 

41-42 
disease treatment and, 23 
economic structure, 30 
functions of, 29-37 
health care and, 23-51 
health care training of, 43 
institution, as an, 28-29 
marriage law reformation and, 28 
performs many functions, 29 
problem -solving system, a, 23 
production unit, the, 30-31 
role of in patient-practitioner rela- 
tions, 25, 43 
unit of medical treatment, as, 23 
China, in, 24 
North America, in, 24 
Family background and professional jobs 

access, 45 
Family behavior and etiology, 46 
Family-community relationships, 24 
Family life and population processes, 

xiii, 24, 26, 28 
Family life, elderly people in, 36-37 
Family planning 

arguments pro and con, 202 
campaigns and problems, 201-206 
Family ties strong for survival, 33 
Fan Ti Hospital, Peking, 273 
i'ansheu, 26 
Fasciolopsiasis buski, 98 



INDEX 



315 



Fat intake and colon cancer, 229-230 

Fees for service, medical, 161 

Feldman, R. M., 238 

Feldshers, Soviet type, 158 

Female infanticide, historic, 199 

Feng, L. C, 262 

Feng, Y. H., 286 

Feng, Y. K., 264 

Feng-shui, 41, 42 

Ferguson, Mary E., 61 

Fertility and mortality rates, 198 

Filariasis, xv, 97, 98, 216, 241, 254-255 

diagnosis, 255 

incidence, 254 

malayan type, 214 

treatment, 2.5 
First aid and the barefoot doctors, 160 
First-aid and the family health 'worker, 

150 
First China Medical Commission, The, 

56 
First Five-Year Plan, The, 144 
First Medical College, Peking, 156 
First National Health Congress (1950), 

142 
First Peking Medical College, 164 
First Years of Yanghi Commune, The, 26 
Five elements, the doctrine of the, 67-49 
Five elements, the tabulated, 70 
Flexner, Simon, 56 
Flora of China, 96 
Fogarty International Center, The, ix, 

xvi 
Folk culture and the Socialist state, 41 
Folk medicine and traditional medicine, 5 
Follis, R. H., Jr., 225, 236, 237 
Food crops production dimination in 

1959-61, 210-211 
Food distribution improvements, 206 
Former mainland citizens, interviews 

with, 27-28 
Four pests, elimination of, 123, 143 
Fox, the folk belief in, 289 
Fox, Theodore, 156, 172 
Fractures, 59 

limb exercise encouraged, 60 

setting, 17 

combined treatment in, 17 

treatment of, 59-60 

mobile splints, by, 14 
"Free Love" not endorsed, 207 



Freud, not now followed in Chinese 

practice, 298 
Friedman, S. M., 187 
Fu, C. K., 261 
Fu, F. Y., 109 
Fu, H., 262 
Furapromidine, chemical structure of, 

251 



Gabriel, A. 238 

Gall bladder diseases, 178 

Galletti, P. M., 237 

Galston, A. W., 236 

Gates, Rev. Frederick T., 55 

Gear, H. S., 283 

Geddes, W. R., 26 

Geiger, H. Kent, 49 

"General strengthening" by acupunc- 
ture, 73- 

Generations and sexes status in the 
family, 24 

Genital organ elephantiasis in filariasis, 
254 

Geographic Health Studies Program of 
Fogarty International Center, x 

Germ theory of disease, 23 

Germ warfare charges against U.S., 119 

Gillan, Dr., 54 

Gingivitis, 86 

Ginkgo, hiloba L„ 98 

Ginseng, 96, 105 

Gliomas, ventricular drainage, and, 59 

Glycyrrhiza glabra L., 99 

Godden, W., 239 

Goiter 

see Thyroid disorders 
control of, 234 

Goitrogens listed, 226 

Gopalan, C, 238 

Gordon, G., 187 

Gordon, J. E., 236 

Gordon, S., 61 

Gould, Sidney, 152 

Governing, actual, and ideology, 9 

Grain production estimated, 220 

Grasshoppers, medicinal, 104 

Great Leap Forward of 1958, The, xi, 
xiv, 12, 13, 34, 123, 143, 146, 147, 
150, 154, 202, 203, 209, 210, 265 
collective childbirth, and, 34 



316 



INDEX 



Great Patriotic Health Movements, The, 

162 
Great Proletarian Cultural Revolution, 

The, 14, 15 
Greene, Roger S., 56 
Greer, M. A., 236 
Guy, R. A., 239 

Gynecologic Malignancy Registry, 271 
Gynura pinnatifida, 96 

H 

Haenszel, W., 238 

Halsted, William Steward, 56 

Hamilton College, New York, xiv 

Han, C. C, 91 

Han dynasty, 54 

medical texts, in, 5 

mental illness beliefs during, 289 
Han, S. C, 236 

Handbook for Barefoot Doctors, 269, 
281 

extract from contents list of, 167-169 
Hansen's disease 

see Leprosy 
Harmony and natural order of human 

society, 6 
Harrington, D. H., 239 
Hatem, G., 303 
Headache 

acupuncture in, 71 
Health behavior and the family, 23-25 
Health care 

adverse conditions and, 141 

auxiliary workers, 143 

basic units of, four, 142 

decentralization of responsibility, 
145 

family, and the role of, 23-51 

family relationship, and, 44 

nurseries, program of, 122 

organization and administration, 
111-190 

personnel and the armed forces, 132 

rural areas, for, 141-152 

schools, in, 119-120 

supplied by traditional practitioners, 
4 

worker' training, 126 
Health centers, rural, 14 
Health conditions and nutrition in pre- 
Liberation China, 216 



Health, general, improvement in, 234 
Health levels and position of youth and 

women in family, 24 
Health manpower, 153-172 

figures for Peking and Thang Lai 
municipalities, 162 

pre-liberation China, in, 153-155 

statistics on, 154, 155, 156 

tabulated, 158 
Health problems, 191-303 

"inroads being made into", 151 

serious, inherited by Communists, 
208 
Health services, rural, expansion of, 141 
Health stations in rural areas, 144 
Health teams, mobile, 15 
Heart disease, 178 
Hemiplegia and acupuncture, 82 
Hen's egg, medicinal, 101 
Hepatitis, 17, 87 

acupuncture far superior to Western 
methods of treatment, 87 
Hepatoma 

clonorchiasis, in, 256 

kwashiorkor, and, 227 
Herba Artemisiac Capillaris, 87 
Herbal drugs, xiv 
Herbal medicine, 154 

cources in curricula at medical col- 
leges, 13, 128 

fifty percent cure rate for cancer. 
277 

research into, 63 

special wards in hospitals for, 10 
Herbal pharmacology, 93 

see also Pharmacology 
Herbal remedies in traditional medicine, 

8 
Herbs, medicinal, processing illustrated 

106 
Herbs, therapeutic properties of. 130 
Hershman, J. M., 237 
Hetrazan, filariasis, against, 255 
Historical factors affecting population 

growth, 199 
History, medicine interwoven with, 93 
Hierarchy of relationships in family, 41 
Higginson, J., 238 
Hinton, William, 26 

Historical development of Chinese health 
aspects, xii 



INDEX 



317 



Ho, C, 263 

Ho, L. V., 109 

Ho, T. H., 284 

Ho, Y., 285 

Ho Ch'eng, 10 

Ho Ch'eng, charge against, 13 

Hodgkin's disease, 272 

Hoffman, D., 238 

Home prescriptions and medical wisdom 

of Chinese people, 13 
Homes for aged, 36 
Hookworm, 56 

see also Ancylostomiasis 

infestations, 232 
Horn, Joshua S., 50, 57, 61, 91, 152, 

216, 222, 236, 283 
Hospital life, mental hospital routine, 

298-299 
Hospitals and Institutes listed, 189-190 
Hospitals 

county, state-supported, 144 

management regulations, 126 

market towns, in, 144 

minority tribes, for, 144 

mountainous areas, in, 144 
Hou, P. C, 238 
Hou, T. C, 109, 262, 263 
Hsia, Tao-tai, xiv, 113-140 
Hsiang, H. C, 261 
Hsiang-t'ung, Chang, 182 
Hsi-ch'ing, Pai, 181 
Hsieh, J. K., 109 
Hsieh, H. M., 109 
Hsieh, S. C, 263 
Hsien-nien, Li, 198 
Hsi-i, 9 

Hsin-hua, Tsao, 49 
Hsu, B., 284 
Hsu, Francis L. K., 49 
Hsu, J. H., 109 
Hsu, P., 109 
Hsu, Y. C, 109 
Hsu, Y. P., 284 
Hsueh, C. C, 283 
Hsueh-tai, Wang, 78 
Hu, C. H., 284 
Hu, C. K., 262 
Hu, C. Y., 284 
Hu, Huang, 181 
Hu, S. K., 286 
Hua Tu, 54 



Huang, C, 262 

Huang, C. S., 261, 283 

Huang, K. C, 286 

Huang, Kun-Yen, 241-264 

Huang, M., 109 

Huang, S. H., 262 

Huang, T. W., 262 

Huang, T. Y., 109 

Huange-tiNei-ching, the, 5 

Huang Ti, "The Yellow Superor", 94 

Huang Ti Nei Ching Su Wen, 53, 65 

Huard, P., 91, 109, 239, 261 

Hueper, W. C, 239 

Human body a sacred treasure, xiii, 53 

Hydrocephalus, 59 

Hydrogen bomb, explosion of, 218 

Hygiene 

campaigns, 46, 121 

environmental, 8 
Hypertension, 227 

I 

Ideology and actual governing, 9 
Ideology, communist, public health, and, 

138 
Illiteracy, reduction of, 234 
Illness, aging and death and the family, 

35-37 
Illness caused by disturbances of yin 

and yang, 6 
Illnesses, Chinese classification of, 25 
Immunization, 160, 161, 162 
I mperata arundinacia, 103 
Inadequacy of medical system in 1969, 3 
Incentives to childbearing, 33 
Income basis in commune living. 29-30 
Income of barefoot doctor, 161 
Increase in number of doctors, great, 156 
Independence of medical profession and 

the Party, 12 
Indigenous medical resources, use of, 9 
Induction period in acupuncture, 82 
Industrial Hygiene Commission, 132 
Industrial Hygiene Institute, 185 
Industrial hygiene work directives, 133 
Industrialization 

China in developmental phase, 29 
the drive for, 3 
Industry, progress in, 217 
Infant and child mortality, 33 



318 



INDEX 



Infant mortality and status of youth, 

24-25 
Infanticide, 199 
Infantile paralysis, acupuncture and, 85, 

88 
Infectious and parasitic diseases, xv, 

241-264 
Infectious diseases, steps against, 124- 

125 
Influenza, 99 

epidemic, acupuncture in, 88 
Insecticides, 99 
Institutes and hospitals under Chinese 

Academy of Medical Sciences, 189-190 
Insulin, synthesis of, 94, 218 
Insurance, labor union, 36 
Integration of medical systems, modern 

and traditional, 10 
Integration of Western and traditional 

medicine, 157 

in rural health centers, 14 
Internal medicine, predisposition to- 
wards, 6 
Intestinal tract diseases and use of raw 

manure in agriculture, 211 
Intrauterine contraceptive device (IUD), 

204 
Iodine content of water in Shansi, tab- 
ulated, 224 
Iodine deficiency and thyroid disorder, 

221, 222 
Iodine excretion studies, 225 
Iodine requirements, factors related to, 

225 
Ipomaeo hederacea, 96 
Iron deficiency cancer and, 229 
[shawata, Y., 239 
Items, standard, used by worker and 

barefoot doctors, 169-171 



Jasmine, Simbac, 54 
Jeliffe. D. E. B., 47 
Jen, S., 91 

Johns Hopkins University, xv 
Johnston, D. M., 187 
fosiah Macy Jr., Foundation, xiii 
Joyet, G., 237 
Judson, H. P., 56 

June 26th Directive of Mao Tse-tung, 
159 



Kahti, Lim, 49, 50 

Kai-shek, Chiang, 154 

Kala-azar, 97, 98, 216, 242, 255 

Kallgren, Joyce, 50 

Kao, J. C, 238, 285 

Kellner, Hansfried, 50, 78 

Kelly, F. C, 236 

Kengshenmycin, tumors, against, 269, 
272 

Kiangsi Soviet and Western medicine, 9 

Kidney inflammation, 17 

Kim, S., 286 

King, Haitung, xv, 265-286 

Kinship ties in rural communities, 31 

Klein, M. E., 238 

Kmet, J., 238 

Knowledge, collected and codified, 35 

K'o, Y. K., 285 

Ko, Y. S., 285 

Kohler, P. O., 237 

Koutras, D. A., 237 

Kraybill, H. F., 237 

Ku, F. C, 261 

Ku, J. S., 284 

Ku, P. C, 283 

Ku, S. Y., 283, 285 

Kung-ch'o, Hsueh, 180 

Kuo, P. K., 262 

Kwangtung Province, traditional med- 
ical treatment in, 16 



Labor, division of, private and public, 
in health care and related industry, 
129 

Labour Hygiene, Environment Sanita- 
tion and Nutrition, Institute for, 148 

Laing, R. D., 47 

Lai, R. S., 237 

Lamson, H. D., 303 

Lancet, The, 156 

Land reform, 28, 29 

Lane health centers, 161 

Large families a Chinese tradition. 205 

Large family system, the, 32-33 

Laws on medicinal materials, 134-136 

Laws on Public Health, xiv, 113-140 

Lay medical care, 44 

Lazure, Denis, 50 

League of Nations, 266 



INDEX 



319 



Learning an attribute of youth, 25 

Leavitt, Milo D., Jr., ix 

Lee, T'ao, 109, 236 

Legal documents and research, 115 

Legal documents applicable to all 

China, 116 
Legal documents on public health, 

grouping of, 117 
Legal documents to be non-technical 

and simple in style, 116 
Legal -political functions of family, 31-32 
Lei, T. M., 263 
Leishmania donovani, 255 
Leitch, I., 239 

Leomurus sibiricus L., 96, 99 
Leong, J. L. ( 238 
Lepromin, visceral source of, 246 
Leprosy, xv, 96, 122, 178 

acupuncture in, 247 

detection of, 246 

distribution in China illustrated, 
245 

drugs used in treatment, 247 

half of world's cases in China and 
India, 244 

incidence, 245 

initial examination in, 246 

Inner Mongolia, in, 246 

lepromin, visceral source of, 246 

leprosaria for, 246 

"leprosary villages", 246 

patient registration, 246 

primary lesion location, 246 

statistics on, 245 

types of, 245 

vaccination program, 247 
Leslie, Charles. 21 
Leukemia, 108 

Leukocytosis in schistosomiasis, 249 
Levin, Harry, 47 
Levy, Howard, 51 
Lewis, John, 42 



L 


, Ching 


-Chow, 91 


L 


, C. C, 


261 


L 


, C. K.. 


261 


L 


, C. T., 


91 


I. 


, F. T., 


261 


L 


, C. T., 


286 


I. 


, H. H. 


, 109 


L 


. K. H. 


238, 285 


I 


, M. H. 


, 284 



Li Shih-chen, 95, 96 

pharmacopoeia of, 6 

Li, T. H, 261, 262 

Li-tzu, Shao, 201 

Li, Y. K., 286 

Liang, Ch'iu, 91 

Liang, P., 303 

Liang, P. C, 238, 283, 284 

Liang, P. K., 61 

"Liberated" Chinese woman, the, 122 

Liberated villages, Army provide medi- 
cal services to, 155 

Liberation of women, 39 

Licensing of physicians, 130 

Life expectancy in 1935 was 28 years, 
216 

Ligusticum acutilobum, 96 

Lim, K. T., 285, 286 

Lin, C. K., 263 

Lin, C. L., 263 

Lin, Y. Y., 285, 286 

Lin-fu, Wei, 49 

Literacy, importance to youth, 39 

IJthospermum officinale, 211 

Liu, B. L., 284 

Liu, C. L., 284 

Liu, C. N., 261 

Liu, E. H., 262 

Liu, Gwei-djen, 61 

Liu, H. Y., 263 

Liu, J., 263 

Liu, J., Heng, 56 

Liu, K. N., 263 

Liu Shao-ch'i, 13 

Liu, S. L., 285 

Liu Shao-ch'i and revisionist clique. 17 

Liu, T., 91 

Liu, Y. C, 261 

Liu, Y. K., 263 

Live births and pregnancies in 1970, 
estimated, 220 

Live cancer incidence, 230 

Liver diseases, 178 

Loaches, medicinal, 101 

Locusts, medicinal, 104 

London, W. E., 237 

Longevity and agricultural work, 21 1 

Lord Macartney's mission to China, 54 

Lotus, medicinal, 103 

Lu, P. Y., 264 

Lu, T. P., 261 



320 



INDEX 



Lucreban-seed, 96 
Luffa Gourd, medicinal, 101 
Luo, M. Y., 261 
Lyman, R. S., 303 
Lymphangitis, 86 
filariasis, in, 255 

M 

MaFua Shuan, the anesthetic, 54 

Ma, H. C, 263 

Ma Shi-Huang, the veterinary surgeon, 

54 
MacDonald, R. A., 238 
Macker, V., 303 
Maccoby, Eleanor E., 47 
Madhavan, T. V., 238 
MaiLo, 69 

Mais-terrena, J. A., 237 
Malamos, B., 237 

Malaria, xv, 97, 121, 216, 241, 252, 254 
anti-malarial drugs, 252 
breeding grounds, 252 
DDT, and, 254 
incidence, 252 

picture of in, China, general, 253 
Malignant neoplasms 

see Cancer 
Malignant Trophoblastic Tumors Dur- 
ing the Last Tivo Decades in the 
Peking Fan Ti Hospital, Progress in 
the Treatment of, 279 
Malnutrition absent from China today, 

217 
Malthus, T. R., 236 
Malthusian theory and birth control, 

201 
Management techniques in public health, 

126 
Manchu Government's attempts at pop- 
ulation enumeration, 194 
Mandarinate, the, 8 
Mann, Felix, 68, 89, 91 
Manpower 

China's largest resource, 141 

family planning, and, 203 

health, pre-liberation China, in. 

153-155 
medical, 148 
Mantel, N., 238 

Manure, raw, use of, intestinal tract 
diseases and, 211 



Mao, S. P., 262 

Mao Tse-tung, 15, 61, 138, 149, 153, 157, 
177 

called for exploration of Chinese 
traditional medicine, 76 

four standards of, 141-142 

"June directive" of, 148 

mental illness, his philosophies and, 
294, 295 

1944 speech, 9 

Norman Bethune, on, 58 

study class in mental hospital, 298 

Thought of, 13 

thought propaganda teams, 39 

thought study classes, 32 
Maoist line, the, 15 
Marcial-Rojas, R. A., 263 
Marine, D., 236 
Marquis, S., 187 
Marriage 

early, discouraged, 203, 204 

five types of, 37-38 

free choice in, 37 

late, considered desirable, 205 

law reform a major factor in fam- 
ily life, 28 

Law, the new, 206 
March, Robert M., 36, 50 
Marxist ideology and human misery, 201 
Materia Medica, Classified, 95 
Materia Medica 

compendium of, 95 

historic review, an, 94-95 

Institute of. The, 94 
May, J. M., 239 
McClelland, David, 42, 50 
McCoy, T. A., 237 
McFarlane, Bruce, 48 
Measles, 45 

freeze-dried vaccines against, 99 
Medical and health care in pre-Com- 

munist China, 128 
Medical Anthropology, 14 
Medical Biology Institute, 185 
Medical care 

accounting, 150 

family unit in China, and the, 24 

hygiene program, and, 121 

lay, 44 
Medical education 

directives, 126 



INDEX 



321 



Medical education (cont'd) 

secondary, emphasis on, 209 
Medical Education and Manpower 
in Communist China, 153 
Medical journals not published since 

1966, 16 
Medical manpower and better health 

conditions, 193 
Medical observers, foreign, visits halted, 

xii 
Medical personnel 
facilities, 125-134 
training accelerated, 153-172, 209 
training, summarized, 167 
Medical practice, Chinese, traditional 

medicine as a basis for, 3-21 
Medical practice, private permitted, 125 
Medical profession's independent status 

a challenge, 12 
Medical research journals as data 

sources, 27 
Medical research organization and pol- 
icy, 176-177 
Medical research under attack, 184 
Medical resources 
ex-urban, 4 
indigenous, 9 
urban concentration of, 4 
Medical schools, 164-166 

recent development of, 155 
Medical sciences, the academy of, 173- 

190 
Medical services 

private and public, regulations on, 

129 
revolution in, 265 
Medical specialists 
artisans, as, 8 
likely to be male, 45 
Medical standards, reduction of in- 
equalities, 150 
Medical synthesis, no theoretical break 

through toward, 14 
Medical teams of the People's Libera- 
tion Army, 151 
Medical textbooks used in U.S. and 

available in China, listed, 233 
Medical texts of Han dynasty, 5 
Medical tradition of People's Republic 
of China, ix 



Medical training 

curriculum described, 165 
shortened, 165 
Medical workers as political figures, 

44-45 
Medical Workers Serving the People 

Wholeheartedly, 57 
Medications and equipment used by 
worker and barefoot doctors, 169-171 
Medicinal Materials, Chinese, 134-136 
Medicinal Materials Corporation The, 

134 
Medicinal plants shown to commune 

members, illustrated, 107 
Medicine 

and -professional move in, 44 
"a tradesman's calling", 12 
Chinese, slow in advancement, 93 
Chinese, a great treasure house, 157 
Confucian disesteem for, 12 
profession, traditional, as a, 8 
sociopolitical influences on, 93 
classical authority, and, 6 
emerging from Cultural Revolution 

not traditional, 18 
interwoven with history and philos- 
ophy, 93 
socialized, 16 
traditional 

see also Traditional medicine 
Medics, education of, the, 127 
Meleny, Frank L., 56 
Memorial Hospital, New York, thyroid 

cancer incidence at, 227 
Meningitis, 120 

tuberculous, 243 
Mental and chronic illnesses in North 

America, 23 
Mental diseases 

see also mental health 
acupuncture in, 292, 293, 296, 300 
changing picture in treatment of, 

302 
chemotherapy, 295 
collective help in, 293 
community ethos, 293 
current scene, the, 292-294 
drug therapy in, 293, 302 
folk beliefs, 288, 289, 290 
follow-up care, 293 
"heart-to-heart talks" in, 293 



322 



INDEX 



Mental diseases (cont'd) 

hospital life, and, 298-301 

hospitalization, length of, average, 
300 

incidence estimates, 290 

Mao Tse-tung's philosophies and, 
294, 295 

multiple techniques in, 301 

patients, the, 294-298 

personnel working in, 298 

productive labor and, 294 

psychiatric theories and, 288 

psychiatry, and 291 

schizophrenia, 296 

schizophrenia most common diag- 
nosis, 297 

self-reliance in, 293 

spirits in, 289 

supernatural elements, 288, 289 

the "bitter past," 288-291 

treatment, xvi, 287-303 

venereal diseases and, 291 

Wu in, 289, 290 
Mental health 

conformity to way of life, and, 288 

organization of Chinese society and, 
287 

politics, and, 287 
Mental hospital conditions, 298-301 
Mental Hospital, Shanghai, 288 
Mental illness and health care, 123-124 
Mental patients, statements by, 294-297 
Meridian and nervous system correspond 

to each other, 83 
Meridian lines in acupuncture, 65 
Meridians, The 

acupuncture and, 69-74 

listed, 70, 71 

nervous system interrelationship, 90 

primary, 71 

research on, 77-78 
Metal needles in acupuncture, 74 
Microbiology Laboratory of East China 
Institute of Sub-Tropical Plants, 182 
"Middle medical schools", 157 
Midwifery was a low-status occupation, 

34 
Midwives, statistics on, 158 
Migration and population registration, 
195 



Miller, E. C, 238 
Miller, J. A., 238 
Miller, J. M., 237 
Mineral analysis of water in Shansi, 

tabulated, 224 
Ming, Chin, 50 
Ming dynasty, 291 

Chinese pharmacopoeia, 95 
Ministry of Commerce, population fig- 
ures of, the, 198 
Ministry of Education, The, 127, 128 
Ministry of Health, 177 

birth control and the, 202 
founded in 1928, 200 
1954 purge of personnel, 10 
policy regarding traditional medi- 
cine, 10 
Ministry of Public Health, The, 127, 

128, 129, 130, 132, 134, 142 
Ministry of Public Security, The, 195 
Ministry of Urban Construction, 132 
Misery, human, and Marxist ideology, 

201 
Missionaries 

medical schools built by, 200 
surgical, 59 
Missionary-founded hospitals and med- 
ical colleges, 12 
Mobile medical teams, 147, 209 

urban personnel in, 149 
Mobile splints and fracture treatment, 

14 
Model communes and children, 34 
Modern Acupuncture and Moxibustion, 

Textbook of, 77 
Modern medical graduates study tra- 
ditional medicine, 10 
Modern medical science, 178-183 
Modern medicine, 
acceptance of, 4 
introduced 100 years earlier, 4 
Modern science and Chinese medicine, 

11 
Modern-trained doctors urged to unite 

with traditional practitioners, 9 
Mongolia, Inner, leprosy cases in, 246 
Monographs on nutrition available in 

China, 233-234 
Montefiore Hospital, New York, xiv 
Morrison, Robert, 154 
Mortalitv 



INDEX 



323 



Mortality (cont'd) 

decline in, 211 

fertility rates, and, 198 

infant and child, 33 

infant, in 1934, 200 

public health and, 208-211 

rates from burns U.S.-China com- 
parison, 58 
Morus alba, 103 
Mother-Son rule, the, 69 
Motherland, medical legacy of the, 1 
Moxibustion, xiii, 63, 65, 75-76, 210 

acupuncture, and, 65 

East Asia, in, 66 

insulation used in, 76 

techniques, 75 

types of, 75 
Muir, E., 244, 261 
Mulberry tree, medicinal, 103 
Murray, M. M., 237 
Muscular dystrophy, 108 
Muscular spasms, acupuncture relives, 

85 
"Museum of diseases and poverty", 

China a, 216 
Mylitta lapidescens, 96 
Myrdals, The, 26, 40, 50 



Nasopharynx, cancer of the, 230 

Nathan, Carl F., 61 

National Institutes of Health, xv 

Nationalistic upswing in arts, 11 

Natural phenomena related to the five 
elements, 67 

Natural resources, accelerated growth of, 
104-105 

Necator americanus, 259 

Needham, Joseph, 7, 21, 61 

Nelumbo nucifera G., 98 

Neoplasms, malignant 
see Cancer 

Neoplastic disease and nutrition, 218 

Nephritis, 17 

combined treatment in, 17 

Nervous system, drugs for, 98 

Network of public health facilities, es- 
tablishment of, 125 

Neural pathway in acupuncture, 78 

Neuralgia, acupuncture as remedy for, 
247 

Neurology, acupuncture in, 85 



Neurology and Psychiatry, Chinese 

Society of, 291 
Neurosurgery, 59 

New England Journal of Medicine, 160 
Newberne, R. M., 239 
New Physician, The, 164 
Nurseries, health care programs for, 122 
Nurses, statistics on, 158 
Nutrition, xv, 215-239 

see also Health conditions 

cancer, and, 227-231 

Chinese Journal of Nutrition, 217 

daily intake estimated, 220 

education, nutritional, 233-234 

five problem areas of, 218 

improvements of past 22 years, and 
the, 234 

lysine deficiency and, 220 

monographs on, 233-234 

nutritional deficiency and infectious 
diseases interplay, 217 

nutritional factors and cancer in 
experimental animals, 230, 231 

nutritional science, its growth in 
China, 215 

nutritional status, general, Chinese, 
231-233 

perinatal, 218, 219-221 

problem for all mankind, a, 218 

protein intake estimated, 220 

rice allocations, individuals, 220 

schoolchildren, in, 233 

study of China's problems a chal- 
lenge to M.S. workers, 234 

thyroid disorders and, 221-227 

vitamins intake, 232 

O 

Observation of family life the sole 

reliable method of data collection, 28 
Occupational choice of family mem 

bers, 30 
Occupational diseases, 122 
Occupational training in the collective, 

35 
Oksenberg, Michel, 48, 50 
Oncomelania hupensis, 249 
schistosomiasis, in, 249 
On-the-job training emphasized for 

worker doctor, 166 
Opie, Eugene, 53 



324 



INDEX 



Opium, 96 

Opium addiction, 216 

Opposition of parents by youth, peer- 
group aid and, 39 

Organization and administration of 
Chinese health care, xii, xiv 

Organization of cancer research, 265-269 

Organization of the family, 24 

Organs and their elements tabulated, 70 

Organs that store and organs that trans- 
form, 67 

Oriental Educational Commission, The, 
55 

Orixa japonica T., 97 

Orleans, Leo, xv, 153, 158, 172, 187, 
193-213, 283 

Orthopedics stressed in training, 58 

Osteohypertrophy, 121 

Osteomalacia, 33 

Osteomyelitis, 54 

Ovarian cyst, massive, removal of, 57-58 

Overpopulation and health care, 141 



Pack, G. T., 283 

Pain, alleviation by acupuncture, 84, 85 
Palos, Stephen 89, 91 
Paragonimiasis, xv, 257-259 

cerebral type, 259 

chemotherapy in, 258-259 

diagnosis, 258 

incidence, 257 

pulmonary type, 258 

tuberculosis, and, 258 
Paragonimus skrjabini, 257, 258 
Paragonimus westermani, 257, 258 
Paralysis 

acupuncture in relief of, 86 

facial, 17 
Paramedical workers likely to be female, 

45 
Parasitic diseases, 43 

drugs against, 97 

elimination of, 209 

infectious diseases, and, 241-264 

major threat to Chinese people, a, 
260 

statistics on, 260 
Parker, Peter, 54 
Parotitis, 86 
Parsons, Talcott, 43, 50 



Party directives and medical education, 

11 
Patriotic health campaigns, 143 
Pasarey, M. A., 237 
Past, the influence of, 3 
Pathology, environmental factors in, 6 
Patient-practitioner relationships, xiii 

family, and the role of the, 25 
Patient treated as a total person, 44 
Patients, rural, handling, 14 
Patriotic public health campaigns, 32 
Parlor, the theories of, 298 
Peabody, Francis W., 56 
Peasant Life in Communist China, 26 
Peasants, behavior of, 25 
Pei yao, 277 

Peking Acupunctural Anaesthesia Co- 
ordinating Group, 83, 84 
Peking Biological Research Laboratory, 

100 
Peking Capital Hospital, 60 
Peking Government, the, commitment 

to health of, xiv 
Peking Medical College, 89 
Peking Union Hospital, 222 
Peking Union Medical College, xiii, 41, 
155, 290 

residency programs at, 56 

Sun Yat-sen a patient at, 56, 57 

Surgical training at, 55 

tumor clinic at, 266 
Peking University, 99 
Pen Ts'ao Kang Mu, his contribution 

to pharmacology, 96-97 
Penfield, Wilder, 59, 61 
Penicillin, 101 

Penicillium islandicum, 230 
People-physicians ratio, 4 
People's communes defined, 29 
People's Liberation Army 

medical corpsmen, 16 

medical teams of, the, 151 

public health work, in, 117 
People's Republic of China 

health manpower in, xiv 

law and culture in, xiv 

medical system in, new, 3 

nutrition in, xv 
Pepper, F., 237 
Perinatal nutrition, 218, 219-221 



INDEX 



325 



Personnel in public health must serve 

the people, 125 
Personnel, medical, and their training, 

153-172, 162-164 
Pests, eradication of, 123, 209, 257 
Pharmaceutical industry, the, 100-101 

self-sufficient, 100 
Pharmaceutical Research, Institute of, 

182 
Pharmaceuticals, Western, unfamiliar to 

Chinese, 138 
Pharmacists and pharmacologists, 158 
Pharmacology, xiii, 93-110 

agricultural productivity, and, 94 
industry, pharmaceutical, 100-101 
modern achievements in, 93 
Pen Ts'ao Rang Mu's contribution 

to, 96-97 
pharmaceutical technology, 94 
pharmacological achievements, 97- 

100 
pharmacological analysis, 94 
research in, 94 

research and development, 97-104 
research and development media- 
coverage, 94 
Pharmacopoeia 
an early, 6 
Li Shih-chen, of, 6 
oldest in world, 95 
Philosophical basis of traditional medi- 
cine, xii, 66-69 
Philosophy, medicine interwoven with, 

93 
Phlebitis, 17 

combined treatment in, 17 
Physical culture promotion, official, 114 
Physicians in China 
number of, 3-4 
licensing of, 130 

regulations pertaining to, 130-131 
traditional, social prestige of, 7, 8 
training of, 155 
Physiological changes induced by acu- 
puncture, 83-84 
Physiology, Institute of, 182 
Phytochemistry, 94 
Ping Pong diplomacy, 113 
"Plagued for centuries by communic- 
able diseases", 241 



Pleurisy, tuberculous, 17, 243 
combined treatment in, 17 
Pneumonic plague, 55 
Pneumoperitoneum, 243-244 
Pneumothorax, artificial, 243 
Poliomyelitis, 99, 108, 242 

acupuncture following, 86 
Political controversy over traditional 

medicine, 8 
Political function of reports of tradi- 
tional medicine successes, 16 
Political functions assumed by families 

under past regimes, 28 
Political-legal functions of family, 31-32 
Political responsibility, collective, 31 
Political stigma blocking career or po- 
litical advancement, 27 
Politics and attitude of individual of 

paramount importance, 164 
Politics and mental health, 287 
Politics and medical workers, 45 
Pollution, regulations against, 123 
Poor, diseases of the, hidden, 24 
Popular press reported medical miracles, 

16 
Population 

attitudes toward modern medicine, 

4 
Confucian admonition, and the, 

198-199 
data 

adjustment necessary, 200 
all-purpose figures, the, 197 
better statistics called for, 213 
estimates and prospects, 211- 

213 
only gross approximations avail- 
able, 212 
the 1953 census, 194-195 
dynamics, xv, 193-213 
factors affecting, historical, 199 
figures of June 1957, 196 
figures, old, inaccurate, 194 
increase, constant, suggested, 201 
population-doctor ratio, 155. 156, 

162 
processes and family life, 24 
processes and family life data 

sources, 26-28 
record, the, 193-198 



326 



INDEX 



Population (cont'd) 

statistics for pre-Liberation China, 

216 
surveys as a data source, 27 
under-thirties constitute two-thirds 
of the, 206 
Populism, medical, 17 
Positive and negative life forces, 66 
Post-Cultural Revolution Period, re- 
search in the, 183-186 
Potter, Jack, 48 

Practical education, emphasis on, 164 
Practitioners, apprentice-trained, 155 
Pragmatic research goals, 174 
Pragmatism and willingness to experi- 
ment highly evident, 302 
Pragmatism in application of ideology, 

157 
Primitive medicine and traditional med- 
icine; distinguishing differences, 5 
Private and public medical services, 129 
Private medical practice permitted, 125 
Preference for traditional medicine, 

population's, 4 
Pregnant women, estimation of num- 
bers of, tabulated, 219-220 
Pre-liberation China, health manpower 

in, 153-155 
Pre-scientific medical systems compared 

with Chinese traditional medicine, 5 
Press in China is didactic, 26 
Press reports as a source of data, 26 
Prestige of youth and women in 

China, has it increased?, 25 
Prevention and causation of disease in 

China, 23 
Prevention and treatment, public health 

laws on, 117-125 
Prevention emphasized in public health 

work, 116 
Prevention in health care, 141 
Preventive medicine by Red Guard 

doctors, 161 
Preventive medicine, emphasized, 208 
Problems, health, in People's Republic 

of China, xii, 191-303 
Productivity and peasant's income, 29 
Professional Manpower and Education 

in Communist China, 153 
Professional specialists' assertion of 
autonomy, 12-13 



Prohibited areas in acupuncture, 74 

Prosser, T., 221, 236 

Prostitution 

houses closed at Liberation, 291 
venereal disease and mental illness, 
291 

Protein, animal, scarce, 220 

Protein malnutrition and liver cancer, 
230 

Prunus mume, 102 

Psychiatric beds, number estimated, 291 

Psychiatric theories, two streams of 
thought, 288 

Psychiatry, political use in Soviet Union, 
301 

Public health 

Communist ideology, and, 138 
Communist Party intentions in, 113, 

114 
education, basic level of, 127 
exacting standards for, 117 
54 documents relating to, 115 
laws, 113-140 

laws versus actualities, 115 
legal sources on, 139 
legislation complete, 137 
management techniques, 126 
mortality and, 208-211 
mountainous regions, in, 134 
People's Liberation Army in, 117 
personnel and facilities, 125-134 
prevention emphasized in, 116 
progress in, 217 
"Rights of the People," and the, 

114 
work reorientation of, 125 
services to be extended, 116 
teacher training courses in, 127 

Publications, professional cessation of, 
xii 

Pulse diagnosis, 73-74 

Pulse lore in diagnostics, 7 



Qingdamycin, a new antibiotic, 182 

Qualifications for Chinese medical prac- 
titioners, 154 

Quality of medical treatment being 
scrutinized in North America, 24 

Quarantine regulations, border, 123 

Quinn, Joseph R., x, xi-xvi 



INDEX 



327 



R 

Radiation for cervical cancer results 

tabulated, 274 
Radical movement and traditional med- 
icine, 9 
Rai, K. C, 237 
Rational theoretical basis of traditional 

medicine, 5 
Rauwolfia serpentinia, 106 
Rauwolfia verticillata, 98 
Read, B. E., 97 
Read, Margaret, 47 

"Recuperation Nurseries" in tuberculo- 
sis treatment, 244 
Red Army Health School, 15 
Red Cross and Red Crescent Societies, 

The, 142 
"Red Guard doctors", the, 159 
Red Guard doctor training of the, 167 
Red Guard doctor usually a housewife, 

161 
Red Guards enforcement of societal 

political values, and, 39 
"Red medical villages", 150 
Redfield, Robert, 5 
Reduction of family impact on youth's 

lives, 42 
References, legal documents, to, 140 
Registration rather than census, 194 
Registers of population, 195-197 
Regulations affecting physicians, 130-131 
Religiosity and women's status, 41 
Renal transplants emphasized, 59 
Report from a Chinese Village, 26, 40 
Report of League of Nations, 155 
Research 

a doctrine for, 173-174 
biomedical, international coopera- 
tion needed in, ix 
cancer, into, 265-286 
cancer, organization of, xv 
development and, reconciliation of 
organizational requirements and 
basic research, 186 
doctrine ambiguous to permit vari- 
ations in policy, 173 
environments and scientific innova- 
tion, 174 
financing of, 179 

following the Cultural Revolution, 
183-186 



goals highly pragmatic, 174 
medical, decentralized, 178 
planning, central national systems 

of, Soviet, 175 
Research Institute of Experimental 

Medicine, 269 
Research Institute of Pharmacology, 

269 
tradition, workers involved in, 173 
Residency programs at Peking Union 

Medical College, 56 
Resources 

manpower China's largest, 141 
natural, growth of, accelerated, 
104-105 
Responsibility, political, 31-32 
Restorative surgery, 57 
Retirement insurance, 36 
Revolution, scientific, China and, 7 
Revolutionary and revisionist lines, 13 
"Revolutionary Committees" running 

educational institutions, 162, 163 
Rheumatic heart disease, 227 
Rheumatism, 178 
Rhododendron Sinense, 54 
Rice allocations, 220 
Rickets, 216 

now eliminated, 160 
Rifkin, Susan, xiv, 141-152 
Robertson, R. C, 237 
Rochester, University of, xiii 
Rockefeller Foundation, 4, 55, 56, 155 
Rockefeller, John D., 55 
Rogers, L., 261 
Role of the family as a unit of medical 

care, 24 
Rules of acupuncture, 71-73 
Rundle, F. F., 172 
Rural areas 

health care, 58, 141-152 
health service emphasis in, xii 
urban personnel aid in build 
ing, 149 
Rural Health Institute, institution of, 

148 
Rural health strategies, xiv 
Rural medical cooperatives, 16 
Rural medical services, city personnel 

in, 147 
Rural medical workers are local people. 
45 



328 



INDEX 



Rural medicinal substances 101-104 
Rural population 80%, 141 
"Rural proletarians" villagers trans- 
formed into, 29 
Rural welfare funds limited, 36 
Ryle, J. A., 237 

S 

Sabin vaccine produced domestically, 

242 
Said, H. M., 109 
Saito, M., 239 

Salaff, Janet W., xiii, 23-51 
Salmon, W. D., 239 
Sanitation 

drives, community, 24 

emphasized, 208 

environmental, 160 

lack of in old China, 216 
Statistics 

health manpower in China, 154, 
155, 156 

health manpower in U.S., 1970, 158 
Scarlet fever, 120 
Schaeffer, B. T., 239 
Schatzman, Leonard, 44, 51 
Schistosoma japonicum, 249 
Schistosomiasis, xv, 97, 99, 122, 216, 218, 
241, 249-251 

controls of, 251 

diagnosis, 250 

dwarfism in, 250 

furapromidine in treatment, 250, 
251 

hepatoma, and, 230 

incidence, 249 

institutes for, 249 

leukocytosis in, 249 

research on, 249 

symptoms of, 250 

treatment, 250 
Schizophrenia most common diagnosis, 

297 
Schizophrenics, statistics on, 298 
Schools, health care programs in, 119- 

120 
Schorr, L. B., 47 
Schoental, R., 239 
Schwartz, H., 228, 236, 238 
Science and Technology 

Commission, The, 179 



resources available for promoting, 

174 
Science and Technology, University 
of, 183 

"Science for everyone, everyone a 
scientist", 173 

Science, modern medical, 178-183 

Scientific achievements, little news of, 
217-218 

"Scientific experiment", the struggle 
for, 173 

Scientific Planning Commission formed 
in, 1956, 176 

Scientific research, 12-year plan for. 
175 

Scientific revolution China and, 7 

Scrimshaw, N. S., 236 

Scurvy, 216 

Scutellaria baicabensis, 96 

Sears, Robert R., 47 

Segi, M., 238 

Selected Papers on Cancer Research, 269 

Self-reliance and mutual help a way of 
life, 288 

Self-reliance policy, development of, 149 

Self-reliance, local, an aim of Party, 16 

Semen strychni, 96 

Service in the health professions and 
family influence, 25 

Sex-role differentiation, 40 

Sexual intercourse, premarital, consid- 
ered reprehensible, 206 

Shanghai Mental Hospital, 297 

Shang-han Lun, The, 5, 6 

Shao-ch'i, Liu, 185 

Shedden, W. W., 236 

Sheeks, R. B., 187 

Shen, L. C, 284 

Shen Nung, 6 

Shen Nung, "Father of Chinese Medi- 
cine", 94 

Shen-nung Pen Ts'ao, The, 5, 6 

Shen, V. P.. 109 

Shou. N. H., 286 

Shu, M. C, 261 

"Sick man of East Asia", the, 113 

Side], Ruth, xvi, 236, 287-303 

Sidel, Victor W., xiv, xvi, 153-172 

Signer, E., 236 

Sika deer, illustrated, 107 

Silicotuberculosis, 243 



INDEX 



329 



Simpson, B. W., 237 

Sino-Soviet cooperation, scientific and 

technological, 179 
Sino-Soviet relations, 139 
Sinusitis, 86 
Smallpox, 120, 123 

vaccination, 118-119 
wiped out, 242 
Smedley, Agnes, 48 
Snails, elimination of, schistosomiasis, 

and, 251 
Snow, Edgar, 205, 207 
Social change advocated by medical 

workers, 45 
Social factors and disease, 23 
Social factors and scientific revolution, 

7.8 
Social insurance and assistance, char- 
tered, 114 
Social position of traditional physician, 

the, 7, 8 
Social services, low level of, 29 
Socialism and folk culture, 41 
Socialization, early, 33-35 
Socialized medicine, 16 
Society, Chinese, historical comments on, 

215 
Sociopolitical influences on Chinese 

medicine, 93 
Sour plum, medicinal, 102 
Soviet advisors to China's medical 

schools, 156 
Soviet experience in scientific research, 

174 
Soviet influence in medical science, 178— 

179 
Soviet Ministry of Public Health and 

the Academy of Medical Sciences, xi 
Soviet model and "middle medical 

schools", 157, 158 
Soviet model for Chinese public health 

program, xi 
Soviet research and public health, ix 
Soviet research system a model for 

Chinese, 174, 175 
Soviet scientific assistance withdrawn 

from China, xi 
Soybean milk and goiter in children, 

226 
Spare Time Clinics, 142 
Spasms, muscular, acupuncture, and, 85 



Spies, J. W., 283 

Splenectomy performed in difficult con- 
ditions, 59 
Squinting, acupuncture anesthesia in 

surgery for, 83 
Starvation, absence of, 206 
State Scientific and Technological Com- 
mission, 176 
Status of family members, 24 
Sterile environment and acupuncture, 

76 
Sterilization, 203, 204 

advocation of, 208 

fear of surgery, and the, 207-208 

methods, improvement in, 204 
Stomach cancer incidence, 229 
Stomatologists, 158 

Stop-gap, traditional medicine as a, 10 
Stott, H„ 237 
Strand, P. J., 238 

Streptomyces melanochromogenes, 269 
Stressful environment, family interac- 
tions causing, 23 
Stub, H. R., 47, 50 
Studer, H„ 236 

Subprofessional and medical care de- 
livery, xii 
Success ratios in acupuncture anesthesia 

tabulated, 89 
Suchman, Edward A., 47 
Suffrage and maternal and child health, 

25 
Sugiura, K., 239 
Suicide, 291 

Sulfuric ether as an anesthetic, 55 
Sun, H. C, 284 
Sun, H. P., 264 
Sun, S. C, 239 
Sung, C. Y., 109 
Sung, Y. S., 283 
Surgery 

acupuncture anesthesia in. 84 

"brain surgery as good as anywhere 
in world", 59 

castration an accepted procedure, 54 

Chung-i, and, 53 

Hua Tan's, 54 

last resort, as a, 53 

low social rank of surgeon, 53 

past and present, 53-62 



330 



INDEX 



Surgery (cont'd) 

Peking Union Medical College and, 
55 

Peter Parker, the influence of, 54 

present-day Chinese, 57-59 

restorative, Chinese emphasis on, 57 

superficial, 53 

superiority of modern practitioners 
in, 4 

surgical missionaries, 59 
Surgical bacteriology, early studies, 56 
Surgical instrument, Chinese, 53 
Sussex, University of, xiv 
Suttmeier, Richard P., xiv 
Synthesis of Western and Chinese med- 
icine, 11 
Synthetic drugs, 97-104 
Syphilis, 56, 143, 291 

eliminated as a major disease, 43 
Systematic description lacking in pub- 
lic health legal documents, 116 
Sze, Szeming, 153, 154, 172 
Szechwan Institute of Traditional Med- 
icinal Materials, 178 
Szechuan Medical College, 182 

cancer research at, 266 
Szutu, C, 283 

I 

Taeuber, Irene B., 49, 236 

Taeniasis, 98 

Tai, T. Y„ 263 

T'ang, C. C, 263 

T'ang, F. F., 262 

Ta'o Hung-ching, 95 

Tao, Wang, 221 

Tatarinov, A., 96 

Taylor, Adrian, 56 

Taylor, C. E., 236 

Taylor, S., 237 

Teacher training courses, public health. 

in. 127 
Technoscientific elite, a, unacceptable, 

173 
Tension between profession and Party 

leadership, 13 
Textbooks, medical, available in China, 

233 
Therapeutic efficacy of acupuncture, 85- 

89 

see also acupuncture 



Third Peking Hospital Psychiatric De- 
partment, 288 

Thought of Mao Tse-tung, 16 

"Three-in-one principle" in medical 
education, the, 166 

Thyroid disorders 

calcium and goiter levels and, 225 

cancer and, 226, 227 

Chinese immigrants to U.S., in, 226 

cretinism and, 226 

endemic areas of world, 222 

England and Scotland, in, 225 

goiter incidence 80% in Yunnan 

Province, 224 
goiter incidences tabulated, 233, 

224 
goitrogens listed, 226 
iodine content of drinking water 

and, 222, 224 
iodization of table salt and, 221 
nutrition and, 218, 221-227 
seaweed and, 221 
soybean milk causing, 226 
thyrotropin and, 225 
tumor, 86 

Thyrotropin and thyroid disorders, 225 

Tibet, Chinese medical teams in. 59 

Tien, C. Y., 284 

Tien, F. M., 261 

Toads, medicinal, 104 

Tonification and tranquilizing effects 
in acupuncture, 72 

Tonsillectomy, acupuncture as anesthe- 
sia for, 64 

Tonsillitis, 86 

Toothache, acupuncture in, 86, 87 

Topley, Marjorie, 42, 48 

Toronto, University of, xiii 

Tovar, E.. 237 

Trachoma, xv, 99, 124, 247-248 
control of, efficient, 247 
education on, public, 248 
incidence of, 247 
"most prevalent disease", 247 
need for continued therapy. 248 
transmission of, 247 
vaccines for, 247-248 

Tradition, distrust of, 17 

Traditional Medicine 
Academy of, 94, 178 
anti-tumor medicine, 269 



INDEX 



331 



Traditional Medicine (cont'd) 
attention to, increased, 11 
auxiliary to modern health care, 9 
barefoot doctors, and the, 15 
Chinese Academy of, 145 
Chinese- American relations, and, 18 
Chinese medical practice, 3-21 
controversy over, 8 
cultural heritage, and, 8 
"cultural nationalism", and, 157 
emphasis on, 177 
empirical base of, 154 
empiricism, and, 7 
equal status with Western medicine, 

210 
examination of by modern method, 

94 
features of, 4-5 
folk medicine, and, 5 
herbal remedies in, 8 
history of, 154 

history of involvement, has a, 18 
integration with modern, 10 
Kwangtung Province, in, 16 
natural resources growth and, 104 
network of channels in body, and, 

69 
new colleges for teaching, 10 
new importance of, 10 
not emerging from Cultural Rev- 
olution, 18 
oldest in the world, 94 
philosophical basis of, 66-69 
practitioners, regulations affecting, 

131 
practitioners training, two methods 

used, 157 
predominant health care method, 

the, 76 
predominating, 4 
public health laws and, 117 
radical movement, and, 9 
reemphasis on, 15 
renewed emphasis on, 17 
research on, 177-178 
rural substances, medicinal, 101-104 
sensitive issue, a, 18 
social position of practitioner, 7, 8 
and status with modern medicine, 9 
stop-gap, as a, 10 



Traditional Medicine as a Basis for 

Chinese Medical Practice, 200 
Traditional Medicine in Modern 

China, xiii, 93, 153 
training of practitioners, 125 
Western knowledge of, fragmentary, 

18 
Western medicine practitioners 

teaching traditional doctors, 129 
Western visitors comment on, 14 
x-rays in, 76 
Traditional and Western medicine syn- 

thesization a goal, 125 
Traditional diagnostics, 7 
Traditional therapy in countryside, 16 
Training of medical personnel, 153-172 
Training of traditional medicine prac- 
titioners, 125 
Transitional society concept, 46 
Transplants, cardiac, early reference to, 

54 
Traumatology, 58 

Travellers' tales as a source of data, 26 
Treatment of the sick, women decide 

on, 35 
Trigeminal neuralgia, acupuncture, 

cured by, 66 
Trophoblastic tumors, results of treat- 
ment tabulated, 273 
"Transitional society" concept, 29 
Ts'ai, J. S., 284 
Ts'ai, N. C, 286 
Tsai, P. L., 261 
Tseng, M. T„ 284 

Tuberculosis, xv, 56, 99. 121, 178, 242- 
244 

acupuncture in, 244 
BCC inoculation in, 244 
chemotherapeutics used in, listed, 

243 
facilities for treatment, 244 
herbal treatment in, 244 
mortality rate, 242 
pargonimiasis, and, 258 
pulmonary, 17 

"recuperation nurseries" in treat- 
ment, 244 
therapeutic measures, 243, 244 
tuberculin positive reactions, tab- 
ulated, 243 



332 



INDEX 



Tumor research, organizations engaged 
in listed, 278 

Tumors 

see also Cancer 
distribution tabulated, 268 
experimental, xv, 268-269 
histologic tabulation of, 268 
Tumors, A Popular Discourse on 
the Prevention of, 271 

Tung, C, 284 

Turtles, medicinal, 104 

Two-track medical education system, 14 

Twelve-Year Plan for Agricultural De- 
velopment, 144 

Typhoid, 120, 123, 216 

U 

Underpopulation, concern about in 

past, 198 
Union Medical College, Peking, 177 
United Nations Population Division's 

population figures tabulated, 212 
Unschuld, Paul, 18, 21 
Urban clinics and hospitals, traditional 

medicine in, 14 
Urban concentration of medical re- 
sources, 4 
Urban doctors rotated into rural areas, 

15, 159 
U.S.-Mainland China communications 

resumption, ix, 90 
U.S. statistics on doctors, dentists and 

nurses, 158 
Uterine cancer 
see Cancer 



Vaccination program against tuberculo- 
sis and leprosy, 247 

Van Wyk, J. J., 237 

Vasectomy, 208 

Vector, disease, attach on, the, 23 

Vegetables in pharmacopoeia, 96 

Veith, Uza, 21, 61, 91, 288, 303 

Venereal disease and mental diseases, 
291 

Venereal diseases under control, 242 

Veratrum schindleri, 98 

Venous anastomosis emphasized in re- 
storative surgery, 57 

Village cadres, age levels in, 39 



Village-level medicine and "barefoot 
doctors", 15 

Village, reorganized after 1949, 28 

Visit to China by Victor W. Sidel in 
1971, 153 

Vitamins intake, 232 

Vitamins manufactured in China, 100 

Voluntarism and Chinese medical work- 
ers, 44 

Von Rottauscher, A., 62 

Vought, R. L., 237 

W 

Wage basis in commune life, 29 
Wallnofer, H., 62 
Wan, T. L., 261 
Wang, C, 285 
Wang, C. E., 286 
Wang, C. F., 263 
Wang, C. J., 262 
Wang, C. L., 261 
Wang, C. N., 263 
Wang, C. T., 109 
Wang, C. Y., 109, 261 
Wang, H. K., 109 
Wang, H. W., 284 
Wang, K. C, 262 
Wang, Liu Hui-chen, 50 
Wang, M., 261 
Wang, S. H., 263 
Wang, T. H., 263 
Wang, T. Y., 284 
Wattenberg, L. W., 238 
Wax Gourd, medicinal, 102 
Wayne, E. (., 237 

"Weaklings of eastern Asia", the, 241 
Webster, Jerome P., 56 
Wei, LuPu, 221 
Wei, R. D., 239 
Wei, S. H., 261 
Wei, W. P., 262 
Wei-p'ing, Wu, 89 
Wei-shen, Chang, 100 
Weissberger, E. K., 283 
Weissberger, J. H., 238 
Welch, William H., 56, 62 
Welfare, abundant, not available, 36 
Wen-chao, Ma, 101 
Wen-chich, Ch'en, 185 
Weng, H. C, 109, 263 
Wenner Gren Foundation symposium, 
18 



INDEX 



333 



Western and Chinese medicine, not ir- 
reconcilable, 106 
Western and Chinese medicine, synthe- 
sis of, 11 
Western "imperialists" and modern 

medicine suspect, 12 
Western medicine and the Kiangsi 

Soviet, 9 
Western medicine, its start in China, 

154 
Western physicians and scientists leave 

China, xi 
Western surgery and China, 53 
Wheelwright, E. W., 48 
White. T. H., 236 
Wigglesworth, J. S., 239 
Williams, W. W., 236 
Willox, G. L., 62 
Wilson, D. C, 237 
Wilson, Richard and Amy, 50 
Wilson, Robert N., 43, 50 
"Witch-doctors", inefficacy of, discus- 
sions on, 44 
Wogan, G. N., 239 
Wogna, G. N.. 239 
Women 

changing status of, 41 

decide who will treat the sick, 35 

interests represented in commune 

and factory, 40 
liberation of, the, 39 
nutrition of, 220-221 

see also Nutrition 
status of, 39-41 

subordination of, relative, 39 
village women's burden not allevi- 
ated, 40 
Wong, Foong, 50 
Wong, K. Chimin, 21, 62 
Wong, M., 91, 109, 239 
Woodham, A. A., 236 
"Workers doctor", the, 159 
Workers and peasant's involved in re- 
search tradition, 173 
World's first nutritional institutions 

founded in China, 215 
Worth, Robert, 14 
Worth. R. M., 283 
Wu, C. C, 109 
Wu, D. Y., 239 
Wu. H., 239 

ft U.S. 



Wu, Lien-te, 21, 62 
Wu, T. Y., 261 
Wu, W. P., 91 
Wu, Y. H., 262 
Wu, Y. K., 238, 285, 286 
Wu, Y. L., 187 
Wuchereria bancrofti, 254 
Wuchereria malayi, 254 
Wyader, E. L., 228, 229, 238 
Wynn, J., 237 

X 

X-rays in traditional Chinese medicine, 
76 



Yang, C, 284 
Yang, C. K., 48 
Yang, C. N., 236 
Yang, J., 284 
Yao-hsueh T'ung-pao, 93 
Yat-sen, Sun, 57 
Yao-hsueh T'ung-pao, 93 
Yeh, C. C, 110 
Yeh, K. S., 239 
Yeh. P. F., 261 
Yeh, S., 237, 284 
Yeh, Samuel D. J., xv, 215-239 
Yellow Emperor, The, 5 
Yellow fever, 123 

Yenan Conference on Culture and Edu- 
cation, The, 9 
Yin and yang, 6, 65, 66-67, 154, 288 
Yn-chieh, Sun, 49 

Youth 

anti-Cancer Shock Brigade. 270 
peer groups, 38 
political obligations, 31-32 
status in the community, 38-39 
status in the family, 37-38 

Yu. A. F., 285 

Yu, C. C, 261 

Yu Fu, the surgeon, 54 

Yu, H., 261 

Yu, H. I... 284 

Yu, T. H.. 261 

Yu, T. T., 261 

Yuan dynasty acupuncture in, 65 



Zoned medical service program, 133 



GOVERNMENT PRINTING OFFICE: 1973 0—472-888 



JUL 3 </ 1973 



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