Barefoot Doctors Research Articles

Leprosy control by a people's program: "a new concept in technology transfer".

Leprosy is a major health hazard in tropical countries as it also is in China. All programs for the control of this disease have been based on the cheap, effective, and low-toxicity antileprosy drug Dapsone (DDS), available since the early 1950s. The emphasis has been on early detection and regularity of treatment, which has to be maintained for several years, if not a lifetime. Despite the availability of what might be rightly termed the "magic bullet," World Health Organization (WHO) figures demonstrate that leprosy has not been controlled in most countries and is generally on the increase. Blame has been ascribed to the patients for hiding the disease and for irregularity of treatment. Emphasis has now shifted to high-technology research to evolve more expensive and much more difficult multidrug regimens and an antileprosy vaccine. China, isolated from the rest of the world and using only simple DDS therapy, but ensuring its use through its barefoot doctor approach, has shown a reduction of leprosy cases from 500,000 to 100,000 in the past three decades. The author suggests that the world, including WHO, should learn from the experience of China rather than try to impose its own low effective and more expensive high-technology approach on this country.

The Whole Emergency Medicine Catalog

The Whole Emergency Medicine Catalog is an interesting book. It contains bits of information that are considered of value to the practicing emergency staff, but it is not intended as a clinical text. Much of the information is displayed in tables, graphs, algorithms, and short sections. Some sections offer essential advice in the practice of emergency medicine; others are useless. The authors admit that the model for this book was the success of previously published departmental catalogs in internal medicine and pediatrics. It is also stated in the preface that the book is not intended to be an all-inclusive textbook. That is indeed the case. The Whole Emergency Medicine Catalog contains some useful information. Unfortunately, it is interspersed with bits of useless data. It takes time to get used to the book before it can be useful as a quick reference. The section on the barefoot doctor's remedies includes treatments

Medical education: barefoot doctors, health care, health education, nursing education, pharmacy education, Part II.

(1987). Medical Education: barefoot doctors, health care, health education, nursing education, pharmacy education, Part II. Medical Teacher: Vol. 9, No. 2, pp. 209-217.

Health manpower allocation in developing countries.

Most developing countries have shortages of health manpower in rural areas. To address this problem, national strategies have included the establishment of salaried posts for rural doctors, construction of rural hospitals and health centres, mandating periods of rural service for all new medical graduates, providing special financial incentives to attract practitioners to rural communities, furnishing transport of personnel, and restricting settlement in major cities. If universal entitlement to health care were legislated for, as in Western Europe and in socialist countries, rural as well as urban populations would be covered. China's development of the “barefoot doctor” dramatised the value of the briefly trained community health worker (CHW) after 1971. Unfortunately, CHWs in many countries proved disappointing, because of inadequate training, poor supervision, and other deficiencies. With political commitment, however, these problems can be overcome.

Medical education: Barefoot doctors, health care, health education, nursing education, pharmacy education, Part I

Medical education: Barefoot doctors, health care, health education, nursing education, pharmacy education, Part I

Oral rehydration in China.

Oral rehydration with salt and sugar solution for diarrhea seems to have been widely used in China for more than 20 years. Surveys in five rural counties in widely distributed provinces have revealed that over 90 per cent of barefoot doctors and county doctors have been using a simple salt and sugar solution. Thirty-four per cent of mothers also said they used the oral solution. By contrast, most urban hospitals, especially teaching hospitals, continued to rely on intravenous (I-V) fluids. It had been previously observed that China has had high morbidity but low mortality from diarrheal diseases. Part of the explanation undoubtedly is the relatively good nutritional status of children and the widespread use of liquid traditional medicines. The finding that barefoot doctors have been using oral rehydration also may help explain the low mortality.

The barefoot doctor: Shanghai County revisited.

Since a 1981 review of health status and health services in Shanghai County, there have been considerable social and economic changes in the People's Republic of China. A major question currently is the impact of the new economic "responsibility system," which was introduced in 1982, on the cooperative health structure and the "barefoot doctors" (BFDs). Investigators in other areas of China have reported the collapse of the cooperative systems and a shift in the role of the BFDs as a result of incentives for them to spend more time in agricultural production. In Shanghai County, however, BFDs continue essentially full time as before, salaried by the brigade, with fee-for-service charges prohibited. Recent evidence from Shanghai County shows that the health care system and those who direct it can remain flexible and respond positively to changes in the social, economic, and political structures.

REGISTERED NURSES: The Barefoot Doctors of the United States

Nursing ForumVolume 22, Issue 3 p. 94-96 REGISTERED NURSES: The Barefoot Doctors of the United States John A. Denton, John A. DentonSearch for more papers by this author John A. Denton, John A. DentonSearch for more papers by this author First published: July 1985 https://doi.org/10.1111/j.1744-6198.1985.tb00779.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume22, Issue3July 1985Pages 94-96 RelatedInformation

Supervised intermittent chemotherapy for pulmonary tuberculosis in a rural area of China

In order to ensure regularity of ambulatory treatment of new cases of pulmonary tuberculosis, a fully supervised intermittent chemotherapy regimen was tried in two rural counties of Beijing. The bare-foot doctors of the village health co-operatives were designated to administer and supervise treatment. The regimen consisted of isoniazid and streptomycin daily for 1 month, then every 3 days for 5 months and then every 5 days for a total of 12 or 18 months. For smear-negative cases the daily phase was omitted. The compliance rate among 229 patients in 1 year was 99.4 %. The sputum conversion rate among 104 cases habouring sensitive bacilli was 95.2 %. Discontinuation of the regimen due to side-effects as necessary in 3 cases (1.3 %). Since 1979, this treatment programme has been adopted in the whole rural area of Beijing, and the coverage rate among newly diagnosed smear-positive cases in 1983 reached 90 %. A reserve regimen consisting of rifampicin and ethambutol for patients who do not convert their sputum after 6 months of treatment with isoniazid and streptomycin was added. The overall conversion rate achieved in 1981 was 97.8 %. The average overall cost of drugs for each patient treated in this treatment programme was 49 yuan (RMB), about $24.00 U.S.

Compliance and Nutritional Status During Feasibility Study for an Intervention Trial in China<xref ref-type="fn" rid="FN1">1</xref>

As part of a pilot study to assess the feasibility of a long-term intervention trial to be done in Linxian, People's Republic of China, nutritional status and compliance were assessed in villagers taking daily multivitamin pills containing the U.S. Recommended Dietary Allowances (RDA). Before the start of the trial and again during its 4th month, nutritional status was assessed by laboratory tests and a dietary interview. Compliance was assessed in all subjects by pill counts and in a subset by urinary riboflavin loading-dose tests. At the outset of the trial, the study population had widespread biochemical and dietary deficiencies of ascorbic acid and riboflavin. As expected, subjects taking a daily pill had significantly improved status for these vitamins during the study. Compliance as measured by pill counts was excellent, with over 90% of the subjects taking at least 80% of their daily pills. Mean urinary excretion of a riboflavin loading dose entered and remained in the normal range after 3 weeks of supplementation, indicating that compliance did not fall off over time. Compliance was similar in normal subjects and in those with a prior diagnosis of esophageal dysplasia. Compliance also was nearly as good in subjects receiving monthly home visits as in those receiving weekly home visits from the barefoot doctor (village paramedical worker). The results of this pilot study indicated that a long-term intervention trial was feasible in Linxian and that the RDA dose level of vitamins was effective in ameliorating certain nutritional deficiencies prevalent in the study population.

Health Care in China

Maternal-child nurses are part of a growing number of Americans who have had the opportunity to visit China. An increased understanding of the history and of the health care practices of the Chinese people lends itself to an examination of American values and health practices. The insight developed may aid us as we seek to understand our own health care practices for women and children and to plan for the future in health care.

Transformation of health care in China.

The evolving Chinese cooperative medical system is examined in an effort to gain some valuable knowledge for both the 3rd world and developed countries. The changes occurring in the Chinese health system are the unintended consequences of economic reforms that have exerted direct and indirect effects on the organization, financing, and delivery of health care. As China does not publish complete or current information on its health care system, the discussion draws on limited published information. China, an agrarian nation, has a population of 1 billion with 80% of the people living in rural areas. A gross national product of US$300/person in 1981 places China in the bottom 1/3 of the developing countries. In 1981 China had 2 hospital beds/1000 people. There are 516,000 senior doctors trained in Western medicine and 290,000 senior doctors trained in traditional Chinese medicine, yielding a ratio of 0.8 senior doctors/1000 people. China also has 436,000 assistant doctors in Western medicine, but most of the primary health care is provided by "barefoot doctors." Hospital beds and health personnel are unevenly distributed between the urban and rural areas. Health personnel, health stations, and hospitals are organized on a 3-tier system. In 1980 China inaugurated major economic reforms in agricultural production and public financing. Alterations in the rural economic structure brought about major changes in the Chinese cooperative medical system. The most influential reform provided financial incentives to peasants, who now receive direct rewards for individual output. Because of economic reform, collective financing and public support for the cooperative medical system diminished. The proportion of the rural population protected by the system has been reduced by 50%. The rapid, continuing decline in the cooperative medical system has affected several important elements of health care: the number of barefoot doctors per capita has diminished; most barefoot doctors forego continuing education; there has been an increase in the financial burden borne by peasants; and hospitals are experiencing financial problems. With the collapse of cooperative health care financing, many barefoot doctors have created private practices, charging patients on a fee for service basis and selling drugs to them. In some brigades, the peasants have organized voluntary health insurance programs, but the peasants face problems in organizing voluntary insurance programs. 1 consequence of the rising income of peasants is their demand for higher quality medical care. The Chinese experience illustrates the effects of economic structure on the supply of health personnel, the demand for services, and the organization and financing of health care. Economic incentives affected the supply of health personnel. Another lesson to be learned is the need to establish a universal, compulsory financial system for health care. The Chinese experience also demonstrates that the pricing structure influences the demand and need for insurance.

Hippocrates unbound. China's medical education for the 1980s.

Working in a Beijing hospital for two years (1979 to 1981), I witnessed a metamorphosis of medical education in China. Walls have been whitewashed to mask discredited slogans of the past. Dining halls have been stratified to separate faculty, workers, and students. Since 1976, the academic program has doubled in length. Since 1979, revitalized basic science departments have enrolled postgraduates. "Worker-peasant-soldier" graduates of 1975 to 1980 have been recalled for remedial courses. Physicians from outlying provinces now staff city hospitals for terms of "advanced study." Barefoot doctors, highly regarded five years ago (but now considered to be only temporary expedients), face proficiency examinations. Doctors with shoes are also newly concerned about professional standards. Since 1977, prospective medical students take a nationwide entrance examination. Medical colleges now maintain transcripts and confer degrees. House staff, graduates of as long ago as 1964, are preparing for board examinations. Educational policy since 1977 is a determined reversal of trends of the preceding ten years.

‘Barefoot doctors’ in rural Georgia: The effect of peer selection on the performance of trained volunteers

Does volunteer selection by peers have a measurable effect on volunteer performance? This paper examines this question in the context of a field experiment which used community organizations as a means to select people to serve as Emergency Medical Coordinators (EMCs). Field sites were 36 rural Georgia communities with populations ranging from 150 to 1850. EMCs were trained in a 40 hour program as first responders to emergency incidents and as organizers of an emergency response system within their communities. Their performance in each of these roles was assessed by composite measures (a first aid performance index and an activity index) developed as part of the study. Each sponsor organization conducted the selection of EMCs for their respective communities. The process was monitored and assessed as either comprehensive, including the evaluation and elimination of candidates, or as unstructured where interested individuals self-volunteered. Performance scores were regressed on the selection process variable as well as a set of structural, predisposing and enabling variables. Peer selection was a statistically significant predictor of EMC performance as a first responder but not as a response system organizer. Implications of this result as well as the influence of other independent variables are discussed.

Introduction to the Control of Measles by Vaccination in the People's Republic of China

Measles vaccine is provided free of charge in China. In big cities the section clinics are responsible for measles vaccination. In rural areas, barefoot doctors go from door to door to administer the vaccine, or parents are told to bring their children to the cooperative medical station for vaccination. In most parts of China, eight months is considered the optimal age for primary vaccination. The seroconversion rates are usually greater than 90%. With the elapse of time, titers of hemagglutination-inhibiting antibody decreased regularly and even declined to an undetectable level. As a result some people who had been vaccinated became ill with measles. Thus, one vaccination cannot guarantee persistence of antibody for life. It would be appropriate to carry out revaccination for maintenance of adequate immunity against measles. In view of the situation in China as a developing country, the main goal of the campaign against measles in the near future should be the broadening of effective vaccination coverage for control of epidemics, the reduction in incidence, and the lowering of the fatality rate. Measles can definitely be eliminated as has already been done for smallpox.

Traveling with the occupational health nurses in China: a perspective today.

Focus in this report of a group tour of occupational health nurses from the US to China and the Philippines in May 1982 is on the visit to Shanghai, Soochow, Peking, and Manila. The trip was designed to develop a professional exchange between the 2 countries and to obtain continuing education units in Occupational Health Nursing. It was an opportunity for the US nurses to personally meet professional associates. Advance reading material was mailed to each tour participant for review prior to the trip. Focusing on the contrasting health delivery care system in China, emphasis was on the traditional and nontraditional treatment methods. Activities such as acupuncture, acupressure, and use of herbs and nontraditional medications were described. Health care in urban and rural areas is contrasted for variances. At this time the treatment theory and practice of psychology in the Western world is being challenged by concepts from other disciplines. Critics of the US model claim that it is culture bound with the disease oriented model rather than the new therapies with the preventive and holistic concept, the body mind integration, and the assumption of responsibility for oneself and the events which occur in one's life. During the tour of Shanghai a visit to the Commune provided an opportunity to experience the agricultural, industrial, and medical environment of that community population. The barefoot doctors today number 1 million and are formally trained in some Western methods. These doctors, usually women have received formal training, generally serve in the community in which they were trained and concentrate on prevention, counseling, and treatment of common disorders. The practice of the barefoot doctor involves counseling in birth control and on the need for birth control and refilling some prescriptions and pelvic reexaminations. As a result of the Commune tour it was evident that Chinese nurses in their Commune hospitals are involved in the total care plan of Commune operations but are not involved in occupational health nursing. The tour group met with the public health and occupational health nurses at the Philippine Nurses Association headquarters buildling. 100,000 registered nurses are spread out over 7000 islands. The occupational health nurses are required by the government to update their education. The Philippine Occupational Health Nurses Association conducts an aggressive educational program with meetings and seminars. Standards of practice for the occupational health nurse are not yet developed, but it is a goal which they expect to accomplish.

The Barefoot Doctors of China: from political creation to professionalization.

The Barefoot Doctor policy of the Peoples Republic of China (PRC) has recently been changed. Rather than remaining a permanent corp of paraprofessionals, Barefoot Doctors (BFD) are to be upgraded, certified, and paid wages for full-time medical work in a process of slow professionalization. This article includes a brief historical description of BFD policy evolution and a literature review that notes problems in the equitable implementation of the original policy. An update in information is added based on original material collected in 1979 and 1981, providing a current picture of efforts to implement the new professional focus. While BFDs everywhere are taking the certification examinations, there are almost no signs of other features of the new policy.

Analysis of illness records for members of two production brigades.

A pilot study was conducted in 2 brigades in Shanghai County China for the purpose of measuring all conditions in persons presenting to the barefoot doctors (BFDs) of those brigades. In January 1981 Bao-bei and Hong-ming brigades of Qi-Yi commune in Shanghai County established patient cards for each member of their cooperative health systems. The BFDs were requested to record the diagnosis and management of all episodes of illness they saw along with the cost of the care. Diagnosis of cases identified from these cards have been analyzed for the January through May 1981 period. A new case was counted for each first visit since January 1981 for a particular episode of a condition or illness. Each repeat episode of a condition (even a chronic condition) was considered a new case if there was an intervening well period. Health cards were created for all cooperative system members in the 2 brigades totaling 3359 (1479 males and 1880 females). The estimated rate indicates that new cases among men were occurring at an average rate equivalent to 2.2 episodes/person per year among females at 3.0 episodes/person per year and for the total population a rate of 2.6/person per year. The proportion of members without any episode of illness was not tabulated in this initial analysis. The classification of conditions or types of illness was based on symptomatic classifications consonant with the diagnostic ability of the BFDs. The most frequent conditions encountered at the brigade level during the 5 month period included common colds bronchitis enteritis (diarrhea) and sprains. Men consistently had lower rates of new cases of illness than women except for tonsilitis and skin diseases. This was particularly the case for genitourinary complaints for which men rarely sought treatment. This was the 8th most common complaint among women. New case rates were 200/1000 in January dropped to 182-187 in February and March and increased to 225 and 267 in April and May. Prevalence data from the survey indicated that the people interviewed in the households from the same general area experienced an estimated monthly illness rate of about 250/1000 similar to the rate of new cases treated during May in the 2 study brigades. This appears to confirm the earlier assumption that cases in this study most likely more closely reflect prevalence than incidence.

Infectious disease morbidity, 1956-1980.

In the past few years in Shanghai County China infectious diseases have posed major health problems. The system for notification and registration of infectious diseases was established in 1956. The county Health and Antiepidemic Station (HAES) was established in 1950. At this time there are 28 reportable conditions. The conditions of cholera plague and smallpox are to be reported immediately by telephone. The others are to be reported using a standard report card developed by the municipal Health and Antiepidemic Center. The report cards are completed at the brigade level by barefoot doctors and at the commune or town level by doctors in outpatient clinics. Cards are to be completed at the time of both admission to and discharge from the hospital. Completed cards are mailed to the HAES. The case notification card contains identifying information about the patient data and place of onset of the condition limited information regarding outcome reporting source and basis for the diagnosis. In the 1956-1980 period a total of 339011 reports of infectious diseases were received at the county level. There has been a significant reduction in the overall incidence/100000 population of notifiable diseases comparing the periods before and after 1965. In the earlier period malaria was the most commonly reported disease with measles in 2nd place. These 2 diseases accounted for 75.6% of all notifications. Consequently emphasis was placed on the control of malaria and measles immunization of children in the county and since 1965 malaria and measles have accounted for only 10.6% of all notifiable diseases whereas dysentery accounted for 46.0% and hepatitis for 26.4%. In 1980 infectious diseases made up 74% of all notifications. No cases have been reported in the past 5 years in Shanghai County. Only 2 cases of polio have occurred in the past 5 years. In 1980 there were 17 cases of encephalitis B reported for an incidence rate of 3 cases/100000 population. Over the 25 year period 31586 cases of viral hepatitis were reported for an annual average incidence rate of 253 cases/100000 population. Major peaks in incidence occurred every 6-7 years. To minimize an expected epidemic in 1979-1980 a series of preventive steps were taken and these are identified. The incidence of bacillary dysentery has not declined significantly over the years.

Rural drinking water supply.

In China since liberation a major focus has been on improving the quality of drinking water. Peasants are urged to drink well water and they are provided assistance in digging wells. This program has been carried out in combination with antischistosomiasis activities. The government has supplied construction materials for wells and the brigades have provided the labor for digging them. Up to 1980 a total of 23 million bricks and 3500 tons of cement had been allocated by the government for this purpose. Most wells are dug rather than drilled for the ground water level is no more than 3-4 meters below ground level. Comparing 1980 with 1949 the number of wells has increased more than 50 times. The population drinking well water has increased 10 times. Along with the development of wells as a source of drinking water for peasants 9 small scale waterworks have been developed in some of the 5 county affiliated towns and 12 relatively densely populated commune seats. The county Health and Anti Epidemic Station supervises hygienic control of drinking water. There are specially trained personnel placed at each commune or town hospital. At the brigade level the primary responsibility for maintaining adequate water supplies and monitoring water quality is with a special fulltime sanitation worker who is supervised by a barefoot doctor. Calcium hypochlorite containing 65% available chlorine is used for disinfection of well water. In order to ensure adequate attention to disinfection of drinking water health aides in each production team are assigned the task of adding chlorine daily to the periodically chlorinated wells and checking continuous chlorinators weekly and adding disinfectant as necessary. Early in 1981 cultures were obtained from 5 wells each of unchlorinated periodically chlorinated and continuously chlorinated types. It has been found that continuous chlorination of wells is preferable to periodic chlorination because if provides more reliable disinfection and saves time and labor. Examinations have shown that more than 70% of wells which are sealed and have hand pumps can meet hygiene standards for drinking water without chlorination. In town running water systems chlorine levels are checked more than once daily and chlorine doses are adjusted to ensure proper residual chlorine levels. Cultures are obtained at least once a month. In 1980 285 samples were examined from 9 waterworks and 81.1% of these were satisfactory with respect to bacteriological requirements.