China's barefoot doctor past, present, and future by krj18645

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needed because no single intervention therapy will                                          10   Dellinger RP, Levy MM, Carlet JM, et al, for the International Surviving
                                                                                                 Sepsis Campaign Guidelines Committee. Surviving Sepsis Campaign.
probably be effective. We should not be discouraged                                               International guidelines for management of severe sepsis and septic shock:
by negative results from the many trials, but should                                             2008. Crit Care Med 2008; 36: 296–327.
                                                                                            11   Russell JA, Walley KR, Singer J, et al, for the VASST Investigators.
continuously think and rethink the basic and clinical                                            Vasopressin versus norepinephrine infusion in patients with septic shock.
strategies to improve the grim prognosis of this                                                 N Engl J Med 2008; 358: 877–87.
                                                                                            12   Annane D, Vignon P, Renault A, et al, for the CATS Study Group.
disease.                                                                                         Norepinephrine plus dobutamine versus epinephrine alone for
                                                                                                 management of septic shock: a randomised trial. Lancet 2007;
                                                                                                 370: 676–84.
*Norbert Lameire, Wim Van Biesen, Raymond Vanholder                                         13   Kelly AM, Dwamena B, Cronin P, Bernstein SJ, Carlos RC. Meta-analysis:
Renal Division, University Hospital, 9000 Gent, Belgium                                          effectiveness of drugs for preventing contrast-induced nephropathy.
                                                                                                 Ann Intern Med 2008; 148: 284–94.
norbert.lameire@ugent.be                                                                    14   Thomas G, Rojas MC, Epstein SK, Balk EM, Liangos O, Jaber BL.
We declare that we have no conflict of interest.                                                  Insulin therapy and acute kidney injury in critically ill patients:
                                                                                                 a systematic review. Nephrol Dial Transplant 2007; 22: 2849–55.
1    Kellum JA. Defining and classifying AKI: one set of criteria.
                                                                                            15   Devos P, Preiser J, Mélot C. Impact of tight glucose control by intensive
     Nephrol Dial Transplant 2008; 23: 1471–72.
                                                                                                 insulin therapy on ICU mortality and the rate of hypoglycaemia: final
2    Murray PT, Devarajan P, Levey AS, et al. A framework and key research                       results of the glucocontrol study. Intensive Care Med 2007; 33 (suppl 2):
     questions in AKI diagnosis and staging in different environments.                            S189 (abstr 735).
     Clin J Am Soc Nephrol 2008; 3: 864–68.
                                                                                            16   Treggiari MM, Karir V, Yanez ND, Weiss NS, Daniel S, Deem SA. Intensive
3    Vaidya VS, Ferguson MA, Bonventre JV. Biomarkers of acute kidney injury.                    insulin therapy and mortality in critically ill patients. Crit Care 2008;
     Annu Rev Pharmacol Toxicol 2008; 48: 463–93.                                                12: R29–38.
4    The SAFE Study Investigators. A comparison of albumin and saline for fluid              17   Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose
     resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247–56.                  control in critically ill adult patients:a meta-analysis. JAMA 2008;
5    Perel P, Roberts I. Colloids versus crystalloidsfor fluid resuscitation in critically        300: 933–44.
     ill patients. Cochrane Database Syst Rev 2007; 4: CD000567.                            18   Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL. Timing of
6    Brunkhorst FM, Engel C, Bloos F, et al, for the German Competence Network                   renal replacement therapy initiation in acute renal failure: a meta-analysis.
     Sepsis (SepNet). Intensive insulin therapy and pentastarch resuscitation in                 Am J Kidney Dis 2008; 52: 272–84.
     severe sepsis. N Engl J Med 2008; 358: 125–39.                                         19   Bouchard J, Weidemann C, Mehta RL. Renal replacement therapy in acute
7    Adolph E, Holdt-Lehmann B, Chatterjee T, et al. Renal insufficiency following                 kidney injury: intermittent versus continuous? How much is enough?
     radiocontrast exposure trial (REINFORCE): a randomized comparison of                        Adv Chronic Kidney Dis 2008; 15: 235–47.
     sodium bicarbonate versus sodium chloride hydration for the prevention of              20   Palevsky PM, Zhang JH, O’Connor TZ, et al. Intensity of renal support in
     contrast-induced nephropathy. Coron Artery Dis 2008; 19: 413–19.                            critically ill patients with acute kidney injury. N Engl J Med 2008;
8    Maioli M, Toso A, Leoncini M, et al. Sodium bicarbonate versus saline for the               359: 7–20.
     prevention of contrast-induced nephropathy in patients with renal                      21   Tolwani AJ, Campbell RC, Stofan BS, Lai KR, Oster RA, Wille KM.
     dysfunction undergoing coronary angiography or intervention.                                Standard versus high-dose CVVHDF for ICU-related acute renal failure.
     J Am Coll Cardiol 2008; 52: 599–604.                                                        J Am Soc Nephrol 2008; 19: 1233–38.
9    Sakr Y, Reinhart K, Vincent JL, et al. Does dopamine administration in shock           22   Tumlin J, Wali R, Williams W, et al. Efficacy and safety of renal tubule cell
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China’s barefoot doctor: past, present, and future
China’s long struggle with rural coverage for health                                        focused on quickly training paramedics to meet rural                                 Published Online
                                                                                                                                                                                 October 20, 2008
care goes back to the early part of the 20th century.                                       needs.5 Most barefoot doctors, who graduated from                                    DOI:10.1016/S0140-
However, these early efforts were seen at that time                                          secondary school education, practised after training                                 6736(08)61355-0

as unsuccessful.1 Although the Government tried                                             at the county or community hospital for 3–6 months.
to draft private practitioners into the rural medical                                       Hence medical coverage in the countryside rapidly
service corps,2 delivery of health care was still scarce                                    expanded (figure).6,7 However, the barefoot doctors,
after 1949. Health-care expenditure for 8·3 million                                         who generated their work points with medical services
urban citizens covered by the state was more than                                           just like agricultural work (ie, their income was counted
that for 500 million peasants in 1964.3 After Mao                                           by transferring time for medical service to similar
Zedong criticised the urban bias of medical services                                        time for agricultural work,) were not at par with the
and pointed out the stress placed on rural areas in                                         regularly trained doctors and their incomes were 50%
1965,4 mobile teams of doctors from urban hospitals                                         lower .
were sent to deliver health care and train indigenous                                         Despite a low level of service in terms of technique and
paramedics.                                                                                 medical instruments, the barefoot doctor programme
  In 1968, the programme of barefoot doctors was                                            effectively reduced costs and provided timely treatment
introduced by the journal Red Flag as a national policy                                     to the rural people.8 The programme also provided other

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                                         Comment




                                                                                                                               doctor was cancelled by the Ministry of Health, and
                                                 Village station (×1000)   Country doctor (×1000)   Health worker (×1000)
                                        400                                                                                    some of them either became village doctors or were lost
                                                                                                                               to other professions. As private practitioners, however,
  Number of personnel or institutions




                                        300                                                                                    village doctors focused on treatment of diseases with
                                                                                                                               economic benefits in mind, such that the public health
                                        200
                                                                                                                               of the village was a low priority.
                                                                                                                                 Collapse of the cooperative medical system and
                                                                                                                               change in the role of barefoot doctors resulted in a huge
                                        100
                                                                                                                               decline in primary health-care coverage in rural areas.
                                                                                                                               On the basis of this rural health policy, the Government
                                          0
                                              1950 1960 1970 1978 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999            proposed the development of a new cooperative
                                                                                      Year                                     medical system in 2003. The new system differs from
Figure: Rural health personnel and institutions in China, 1950–2000                                                            the old: it is organised and financially supported by the
Note that x-axis is non-linear. Data are from references 6 and 7.                                                              Government. The local government pays 10 Renminbi
                                                                                                                               per year for everyone covered by the new system, and
                                                                  services, including immunisation, delivery for pregnant      the fund covers the costs of serious diseases. The new
                                                                  women, and improvement of sanitation. Rather                 system also faces serious challenges, such as how to train
                                                                  than herbs and acupuncture, antibiotics and western          village doctors and what kind of service is to be provided.
                                                                  medicines were prescribed and even simple surgical           Meanwhile, disease prevention and public-health efforts
                                                                  operations commonly done. Thus the arrangement               remain ignored.
                                                                  solved the distribution of health-care resources under         The barefoot doctor was an attempt by the
                                                                  the urban–rural dual-economic system, and played             Government via political mobilisation to solve the basic
                                                                  an important part in modernising health care in rural        health-care problems of rural areas when the nation was
                                                                  China.9 WHO regarded China’s barefoot doctor system          developing. Despite critiques, people have a generally
                                                                  as a successful example of solving shortages of medical      positive memory of the barefoot doctors who provided
                                                                  service in developing countries.10                           equitable medical services, especially when the health-
                                                                    Although training of barefoot doctors was varied           care crises of peasants substantially increased after the
                                                                  (and recruitment depended on a candidate’s political         system broke down in the 1980s.
                                                                  attitude and local relationships rather than educational       The new cooperative medical system tries to meet the
                                                                  background), most of them were still interested in           medical needs of peasants, but it still faces challenges,
                                                                  improving their skill and having better training. In 1975,   such as how to balance clinical service and public health,
                                                                  the then vice-premier Deng Xiaoping pointed out that         how to ensure the qualifications of the village doctor
                                                                  the barefoot doctors would improve their knowledge           and provide their income, and how to manage and
                                                                  gradually and “put on shoes” in the future.11 However,       allocate resources. The new system, which draws heavily
                                                                  Deng’s idea was criticised for dividing itself from          on the experiments of the barefoot doctor programme,
                                                                  agricultural production. During the Cultural Revolution,     will take responsibility for the health care of peasants in
                                                                  there was a constant tension between improving               rural China.
                                                                  educational quality and pursuing political goals of mass
                                                                  production.                                                  *Daqing Zhang, Paul U Unschuld
                                                                    Reforms in the health-care system in the early 1980s,      Centre for the History of Medicine, Peking University, Beijing
                                                                                                                               100191 (ZD); and Horst-Gortz-Stiftungsinstitut fur Theorie
                                                                  which were unsuccessful during this period, resulted
                                                                                                                               Geschichte und Ethik Chinesischer Lebenswissenschaften, Charite
                                                                  in the collapse of the cooperative medical system to a       Universitatsmedizin, Berlin, Germany (PUU)
                                                                  payment-based system of medical care in rural areas.         zhangdq@bjmu.edu.cn
                                                                  The percentage of villages with a cooperative medical        We declare that we have no conflict of interest.
                                                                  system fell from 90% in the 1960s to 5% by 1985.12           1    Li TA. Report on Chinese Rural Healthcare Inquiry. Chin Med J 1934;
                                                                                                                                    20: 1113–1201.
                                                                  Barefoot doctors thus lost their institutional and           2    Chen HF. History of Chinese healthcare. Shanghai: Shanghai Science and
                                                                  financial support. In January, 1985, the title of barefoot         Technology Press, 1993: 267.



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                                                                                                                                                                   Comment




3   Huang SZ, Lin SX, eds. Health in modern China. Beijing: Chinese Social        9    Editorial. Impose revolutionary measures on training rural healthcare
    Science Press, 1986: 13.                                                           personnel. Health News, Aug 14, 1965: 1.
4   Mao ZD. Long live Mao Zedong thought. Internal Sources, 1970: 135.            10   Zhang ZK. Retrospective study on Chinese rural cooperative medical
5   Anon. The orientation of the revolution in medical education as seen in the        system. Chin Rural Health Serv Manage 1994; 14: 4–9.
    growth of barefoot doctor. Red Flag 1968; 3: 20–26.                           11   Zhang ZK. The advance direction of rural healthcare personnel—
6   Cui YL. Chinese annals of health. Beijing: People Health Press, 1984: 60.          30th anniversary of De Xiaoping’s speech on barefoot doctors.
7   Ministry of Health. Chinese annals of health statistics. Beijing: Peking           Chin Rural Health Serv Manage 2005; 25: 5.
    Union Medical College Press, 2005: 54.                                        12   Anon, ed. How to make cooperative medical system work well? Vol I–III.
8   Lampton DM. The politics of medicine in China. Dawson: Westview Press,             Beijing: People Health Press, 1974.
    1977: 229.




Medical research ethics in China
Medical research ethics has been a growing issue in                                 There are two major criticisms of the principle-based                       Published Online
                                                                                                                                                                October 20, 2008
China over the past two decades. In the 1990s, many                               framework in China. The first concerns whether, and                            DOI:10.1016/S0140-
relevant documents were translated into Chinese, and                              how, a framework that focuses on individual autonomy                          6736(08)61353-7

many ethics workshops were held in major Chinese                                  can coexist with a traditional ethic that emphasises
research centres. Initially, momentum was generated                               social harmony over individual interests. This debate is
by the need for ethical review in collaborations funded                           part of the worldwide critique of ethical imperialism,6
by international scientific agencies and the drug                                  to which some have responded that principle-based
industry. The Ministry of Health issued requirements                              ethics are universal and compatible with other ethical
for good clinical practice in 1999 (revised in 2003)                              systems7 whereas others have argued that many medical
that also included ethical review. Another factor has                             moralities coexist in all societies.8 As with virtue-based
been the recent trend toward documentation by                                     ethics in developed countries,9 traditional Chinese
ethics committees before publication in international                             ethics focus on relationships and the responsibility of
journals. The protection of human participants in                                 a person to work for the good of others, rather than
international medical research collaborations in                                  adherence to general principles of common morality.
China, and in other developing countries, has been                                Some contend that this ethic undermines the protection
a focus of attention in the mass media in developed                               of individual participants in medical research.10 However,
countries and in the scientific literature. These moves                            leading Chinese bioethicists argue that virtues and
have provided models for ethical implementation1                                  ethical principles are compatible, and that respect for
and brought attention to the controversies around                                 people, non-maleficence or beneficence, and justice
the protection of participants in clinical trials and                             are principles and virtues for a good person.11 For
observational studies.2,3 Recently, as research funding                           medical research, major ethical responsibility is placed
from Chinese governmental sources has increased, so                               on the researcher. Thus a signed consent form might
also has the requirement for ethical review of domestic                           be seen less as protection for participants’ rights than
research protocols.                                                               as a legal mechanism that will relieve researchers from
   Currently, most of the ethical codes for medical                               their important virtue-based responsibilities. To further
research, including the regulations issued by the                                 the goals of the ethical conduct of medical research,
Ministry of Health in 2007,4 are based on the principles of                       it is essential to continue to clarify how principles and
autonomy, beneficence, and justice. Autonomy includes                              virtues can be used together to enhance the protection
situations when consent might be compromised by low                               of participants.
literacy or mistaking research for routine health-care                              The second critique takes a broader view of the
services.5 Justice considerations can arise when large                            purpose of medical research ethics, beyond both
drug-company trials are done in less developed regions                            the function of institutional review boards and
(the findings might not be reported back to participants                           their principle-based reasoning, and assessment of
and their communities, or the standard of care in such                            actions based on good intentions or achieving good
trials might be measured by domestic rather than global                           outcomes. Reflecting recent discussions of professional
standards).                                                                       ethics in the context of market reforms,12 this critique

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