was devised the concept of the "barefoot doctor" and other paramedical personnel. (1) Barefoot doctors-to "serve the people" over a million barefoot doctors, both male and female, have been trained. The connotation "barefoot" merely identifies them with the workers and peasants, with whom their work is chiefly concerned. Basically, the barefoot doctor is a middle school (junior or senior high school) graduate who has been selected by community leaders and peers as being intellectually and ideologically fit for training. Usually 3 months are spent in a district hospital gaining knowledge and practical experience in primary medical care, first-aid, sanitation, health. education, immunizations, acupuncture and traditional medicine. Many subjects in which students are trained are, in the United States, considered the domain of the physician, i.e., suturing wounds, using antibiotics and other drugs. Training continues more or less on a regular basis with refresher courses at the center nearest the place of assignment. Longer periods of training are provided for advanced studies at a regional center. In time a barefoot doctor can become. as well trained as a medical school graduate. A varying number of families or workers is served by the barefoot doctor but the patient load appeared not to be overly burdensome. He or she is expected to have intimate knowledge of the chronically ill requiring regular check-ups, medication, further evaluation or referral; to provide primary care for acute illnesses and accidents; to keep immunizations up to date; to give birth control counselling; and to oversee sanitation problems (i.e., water sterilization and night soil preparation). The barefoot doctor also performs a regular work task in addition to his medical duties. There are still other categories of worker-doctors and health workers. Although their place in the health care system is important, the scope of their training and duties apparently is less demanding than in the case of the barefoot doctor. Their assignments seem to involve smaller groups of patients, whether at work or among families. (2) Medical Doctors.-The training of physicians ceased in the People's Republic from 1965 to 1970. After that time, the period of training was reduced to 3 years and the curriculum shortened from 30 or more courses to 15-17 encompassing along with modern techniques both traditional medicine and acupuncture. Students for this training are selected in a manner similar to that used for barefoot doctors and usually have had several years of worker experience after graduation from middle school. A brief internship is served by graduates of medical school before they are sent to serve in a setting of need. After completing a period of community service, they may be considered for specialty training. (3) Nurses.-The training period appears to be about 18 months. Some nurses are selected for schooling as physicians which requires another year. Their responsibilities are closely related to hospital work. (4) Midwives-Much of the maternity work is done by midwives whose training is 1-3 months. During that period they cover much of the ground that is contained in the barefoot doctor's training, with special emphasis on obstetrics. COMMUNICABLE, INFECTIOUS AND PARASITIC DISEASES Neither prostitution nor venereal disease is a current problem in the People's Republic. Both were identified in mass public education campaigns as legacies of the old society and the cooperation of the people resulted in their elimination. Initially, houses of prostitution throughout the country were closed. Inmates were treated, rehabilitated and assigned constructive work. Venereal disease case finding throughout the country was accomplished by questionnaires, barefoot doctors, health workers and concerned citizens. It was found that unskilled medical workers with a week's training were 90 percent accurate in case finding. Rapid and simple blood tests were used. Treatment with penicillin proved effective. Fulfillment of the following standards over a five-year period was considered as eradication: 1. All cases in the community were found and treated. 2. No new cases. 3. No signs of clinically active syphilis present. 4. All newborn children free from congenital syphilis. 5. Previously treated syphilitic mothers have the same pregnancy outcome in subsequent pregnancies as uninfected mothers. Through the health care delivery system the following immunizations are given: 1. BCG (against tuberculosis)-Initial vaccination is performed within 3 days of birth. Tuberculin testing is performed every 3 years and a booster BCG is given if tuberculin test is negative. 2. Poliomyelitis-Oral (live, attenuated) vaccine is given at 6 months in 3 doses at monthly intervals; 3 doses are repeated at one year and again at ages 5-7. 3. Triple Vaccination (diphtheria, pertussis and tetanus)-The initial three doses are given at 3 to 6 months; single booster doses are given at ages 3 and 6. 4. Measles Initial immunization is given at 6 to 8 months to children with no history of measles; boosters are given 3 to 5 years later. 5. Small Pox-Initial vaccination is given at 6 months, with revaccination at age 6. 6. Japanese B Encephalitis-Immunization is given annually in October or November in certain provinces to children under age 14. 7. Mennigococcal Meningitis (Groups A & B)-Immunization is given annually in October and November in certain provinces to children under age 14. Tuberculosis has been brought under control through case finding and early treatment. This achievement is the more remarkable, considering the crowded living conditions and very high incidence (10 percent, for example, at Peking University) prevalent prior to these measures. In bringing it about, mass education programs were widely employed, with emphasis on the advantages of early treatment. Portable x-ray units, including field out-of-doors operable fluoroscopes were also used to help with case findings. Schistosomiasis, a parasitic disease, continues to be a major health problem. Nevertheless, effective efforts have been made to control and reduce its incidence. Mass education through lectures, films, posters and radio have been used to control the snails, the intermediary host. I was advised that by draining infected ponds, treating and deeply burying the infected soil, schistosomiasis has actually been eradicated, for example, in the Kwangsi Chuang Autonomous Region and brought under control in Yunnan Province. Early treatment and surgery on more serious cases have also proved effective. Kala-Azar, a long time scourge of certain coastal areas, has been eliminated by control of the transmitting agent, the sand fly. Malaria continues to exist in the more remote parts of the southernmost provinces. Preventive measures and mosquito control are in active use. Other Safe drinking water programs, improved personal hygiene, treatment of human excreta before its use as fertilizer and control of dogs have also cut down on the incidence of parasitic and infectious diseases. TRADITIONAL MEDICINE AND ACUPUNCTURE Traditional Chinese medications by the thousands are available in the People's Republic, and more are being discovered all the time by the diverse health systems and by concerned citizens. Tree bark, herbs, fungi, certain animal skins, insects, etc, are in wide use. Good results have been claimed for these medications in the treatment of pneumonia, nephritis, hypertension, heart attacks, angina, appendicitis and many other conditions. Since many useful pharmaceutical agents are known to come from natural sources, (i.e., digitalis, ephedrine, reserpine, quinidine, anti-cancer agents, etc), it is not unreasonable to assume that a treasure house of new effective drugs might be developed from these traditional medicines. Certainly, every effort should be exerted to carry out appropriate controlled research and this apparently, is what the Chinese are doing at this time. Acupuncture anesthesia has captivated the attention of the West. since 1972. Many competent western physicians have observed acupuncture anesthesia at work in China for a myriad of operative conditions-brain, thyroid, open-heart, lung, stomach, orthopedic surgery to name a few. Its proponents can point to its safety, simplicity, inexpensiveness, lack of side and after effects and rapid patient recovery. The mechanism of action and the universality of its usage remain to be worked out by research and additional experience. However, it is currently widely used as an anesthetic in China. Acupuncture as a treatment has been practiced for over 2,000 years in China. It is applied for almost every condition, with many visitors having observed its use, with reported good results, for stomach ulcers, hypertension, paralysis due to multiple causes, as well as for painful conditions such as headache, back pain, arthritis, and bursitis. Development of acupuncture points on the scalp and ear, electrical stimulation of the needles and injection of traditional medicine at acupuncture points are new amplifications of the treatment. Thorough research is needed concerning its mechanism of action and the universality of its applicability. MEDICAL FACILITIES It is said that every county in China now has a hospital. Many of the larger communes have small hospitals. Most of the brigades have a cooperative medical center. Most of the production teams have clinics. Those hospitals and other facilities are not modern or well-equipped by U.S. standards but the quality of care and individual attention seem to make up for these shortcomings. The laboratories, radiology and radio-isotope departments which were seen were well-equipped. Cleanliness of the floors, passageways and reception areas was remarkable. MEDICAL COSTS For a small registration fee (equivalent to 2-5 cents), a factory worker receives free medical care. If hospitalized, he pays a small additional fee for medication. If disabled or sick, he receives full pay up to six months. If permanently disabled, compensation is at full pay or 70 percent, depending on whether he has worked 15 years. His dependents pay one-half of their medical costs. A farm worker pays about twenty-five cents per year for cooperative medical care. Disability benefits in the rural areas are not known. CANCER Prior to 1949, cancer ranked tenth as a leading cause of death. As a result of drastic reductions in mortality from other causes by effective control of infectious and parasitic diseases, improved nutrition and universal health care, cancer now ranks number one. Cancer of the esophagus is the most prevalent type and the leading cause of death in some areas. Its etiology has been linked with chemical water contaminants and certain fungus growths on preserved food. Cancer of the uterine cervix is routinely screened for in all susceptible age groups every two years. Breast cancer is not common but is checked for at times of routine examination. Although there are relatively few motor vehicles, there is widespread use of soft coal in industry and for heating. Air pollution from this source was discernibly heavy in Peking, Shanghai, Kuang-chou and Kun-ming. Cigarette smoking is very prevalent among Chinese males but is rare among females. Cancer of the lung is on the increase, but no official stand has yet been taken regarding the hazards of cigarette smoking. MENTAL HEALTH Mental illnesses apparently have not become a major health problem, although information is not detailed concerning their prevalence. The cohesiveness of the society in small groups, and the beliefs in the malleability and perfectability of man have helped develop new techniques of treatment through collective help, self-reliance, "heart-toheart" talks, productive labor and "revolutionary optimism." Westernstyle drug therapy and acupuncture are used in conjunction when appropriate. The reported "cure" and "much improved" rate is astonishingly high. MISCELLANEOUS Re-implantation surgery for severed fingers and extremities has been highly successful. Meticulous micro-techniques for joining minute veins and arteries and the referral system of cases has attracted the attention of the entire medical world. New techniques appear to have been developed to allow survival of burn patients with 90% body burn, a most extraordinary achievement. By timely and proper fluid replacement during the early shock stage, progression has been allowed to the period of infection which has been dealt with by isolation of the patient, supportive therapy, rational use of antibiotics and proper management of burn wounds. The reported success rate and the enthusiasm of American medical observers strongly suggests the need for further investigation for possible universal adoption. Neither alcoholism nor drugs are considered to be problems in the People's Republic. The People's Republic has persuaded the national minorities in the Southwest who were the principal growers of poppies to shift to other crops although some production of opium for medicinal uses within the country, under strictly controlled conditions, is permitted. From time to time, allegations have appeared in the press that mainland China is the source of large quantities of narcotics entering the illicit international drug trade. U.S. Drug Enforcement Administration officials in Hong Kong stated to me that there is no evidence that China is a source of illegal narcotics. This assurance confirmed what had been told to me earlier by Chinese officials. Hypertension seems extremely common, especially in Peking and the discovery of its cause may shed light on this problem for the rest of the world. Previously, the life expectancy at birth in the People's Republic of China had been reported to be 53 years. Victor W. and Ruth Sidel in their new book, Serve the People, state that life expectancy at birth in Shanghai (73.3 years) is greater than that in the United States (70.4). Dr. Ma Hai-teh (George Hatem), an American born doctor who is a long time resident of China, also stated that life expectancy in China is now slightly more than 70 years. Whatever the accurate figure, it is evident that the Chinese have made remarkable accomplishments in health care delivery, disease prevention and disease control during the past 25 years. They are using contemporary western medical concepts together with new techniques in traditional Chinese medicine. The combination is producing promising results, which could be of benefit to the entire world. POPULATION POLICY China's chief delegate to the U.N. World Population Conference last August announced that the country's population was "almost 800 million." There is considerable uncertainty about China's rate of increase, with most U.S. experts judging it to be at somewhat less than two percent, or about fourteen million a year. It is said that the goal is to reduce the rate to one percent by 1980. All external estimates should be taken with a grain of salt. China's population policy involves a selective approach. For example, late marriage and birth control are encouraged in areas where population density is high. On the other hand, population growth is not discouraged in sparsely populated regions where many of China's minorities live. The annual population growth rate is .48 percent in Shanghai and .97 percent in Peking. In Inner Mongolia, however, the growth rate is 2.1 percent and in the Sinkiang Uighur Autonomous 54-692 O 75 - 2 |