Medical Minefields: Thinking about Terminology
To broach the topic of health and medicine in modern China, one must begin with a consideration of terminology. Although terms such as “Chinese medicine” and “Western medicine” can seem self-evident and obvious, they are nonetheless terms that are profoundly imbricated in specific historical contexts and moments. Up until the 19th century, there was no Chinese medicine; there was “medicine” (yi), a term that encompassed all forms of medicine and healing as well as those engaged in such activities, be they an imperial physician (tai yi), an itinerant peddler of medicines (ling yi), a quack (yong yi), or a Confucian physician (ru yi).1 With the 19th and 20th century encounters with the West, yi lost its older, neo-Confucian connotations of virtue and good stewardship and no longer denoted the whole cultural field of healing. Yi needed to be qualified and modified by terms such as Chinese, Western, old, new, national, etc. As Bridie Andrews has emphasized,
The act of splitting and renaming what had previously been merely aspects of yi emphasized newly contrasting epistemologies of health and disease. Today, it is easy to take these separate categories as natural and to forget that they are artificial derivatives of what was once a single, complex field of activity. The concept of Chinese medicine did not exist until Chinese physicians found themselves forced to define their field in order to distinguish it from the medicine of the West.2
For this reason, Chinese medicine (zhongyi) is better understood as a marker for an assemblage of theories, technologies, and practices that defy simple definition. Interactions with Western colonialism, scientific ideas, and new biomedical technologies shifted the organization and composition of existing theories, technologies, and practices—sometimes minimally, sometimes in quite unexpected and profound ways. Western medicine (xiyi), for similar reasons, traversed a similar pattern. Since the 19th century, Western medicine has been used inconsistently to refer to Chinese physicians who had studied abroad, foreign medical missionaries residing in China, as well as an approach to medicine and healing based in biochemistry, anatomy, and physiology.3 Both of these terms, Chinese medicine and Western medicine, have served as counterpoints or counterposing partners that implied contrast with its civilizational other. The rhetorical content of this juxtaposition rang clearly, even if neither of these terms had a fixed meaning or a single object of reference beyond the implied contrast.
Thus, rather than presuming that either Chinese medicine or Western medicine refers to a universally consistent corpus or monolithic entity, both of these terms are used here with the understanding that they reference continuously evolving systems composed of a series of interlocking, sometimes self-contradictory, parts that have varied widely by time period, location, practitioner’s social status, and other factors.
The use of the terms Chinese medicine and Western medicine is a shorthand here that indexes practices, ideologies, and institutions associated with these terms in the historical moment under consideration. In many instances, the term Chinese medicine in this article refers to what some have called traditional or classical Chinese medicine, indigenous to China and informed by ancient texts and folk practices, as distinct from “biomedicine,” or Western medicine, informed by the life sciences, laboratory research, and with roots outside of China. When all forms of healing in China, including both Chinese medicine and Western medicine and biomedicine, are being referenced, the term “medicine in China” is used instead. One final comment about terminology that one will encounter when considering health and medicine in modern China: “traditional Chinese medicine,” or TCM, is a term that is more common outside of China. It has different valences ranging from general equivalency or interchangeability with Chinese medicine to a more specific reference to a form of medicine that emerged after 1949 and was standardized and promoted on a nationwide scale by government-run institutions, especially from the 1950s through the 1990s.4 Increasingly, scholars have also adopted a further lexical distinction between TCM and 21st-century “Chinese medicine and pharmacotherapy” (zhongyiyao, CMP), with the latter representing the hybridized aspects of Chinese medicine, as well as taijiquan, qigong, and other meditative practices populating wellness markets that have gone global.5 These terminological differences remind one that the terms being used cannot be taken as having an obvious, self-evident referent. They change and will shape how one approaches the topic at hand.
Who Was a Physician? What Did Medicine Include?
Throughout much of the modern period (late imperial through the 20th century), healing activities have been pluralistic and diverse in nature. There were fluid boundaries between curative and health-promoting activities, and those providing health services came from a variety of backgrounds and trades. Indeed, the types of healers were as varied as the methods employed. Some worked exclusively as doctors, spirit mediums, or specialists of gynecology or orthopedic manipulation, to name a couple. They may have inherited their knowledge from family members or as apprentices within a famous medical lineage. They may have been part of the scholarly elite or itinerant doctors or peddlers of Chinese drugs. Others may have engaged in medicine and healing as one of several income-generating activities, provided medical advice in temples, worked as massage therapists, or worked as traveling dentists who could extract a troublesome tooth for a fee. Although most practitioners were male, women too were engaged in the healing arts as midwives, specialists in pediatric care, and as smallpox variolation specialists. Within a cacophonous medical marketplace and a legal context that did little to regulate or control the provision of health services, the ability to attract patients became the baseline criterion for who could be a healer.6
For the person seeking advice and care, this pluralistic and eclectic medical landscape nurtured certain tendencies. Friends and family were often the first recourse for diagnosis and treatment. Their guidance constituted one part of a rich ecosystem of everyday knowledge that helped people decide what to eat, what tonics to use, and what charms to hang. Beginning in the 16th century, “daily use encyclopedias” (household reference works) became popular and provided advice on a range of topics, including health and medicine, practices such as regulating one’s waking and sleeping with the rhythm of the seasons, abstaining from excessive emotion or physical indulgences, and meditative and gymnastic techniques associated with “protecting life” (weisheng) and “nurturing life” (yangsheng).7
With the onset of illness or disease, it was not uncommon for a person or family to seek as many practitioners as they could afford, be it sequentially or simultaneously—all the while comparing, modifying, and even rejecting the received recommendations based on their own sense of what was appropriate. This sense was nurtured and sustained by the greater availability and accessibility of all manner of texts that came about with the growth of print in the commercialized, urban culture of the Qing after the 16th century. Not only was it easier to obtain medical literature, it was easier to get one’s medical opinions printed. Cheap texts for the masses on drugs and medicines, medical primers, and household manuals directed at laypeople were all available and provided guidance for those seeking health assistance. Novels and dramas too could be mined for medical prescriptions. Literate men and women who practiced medicine as a hobby often compiled and printed their own medical works containing selected excerpts from other texts, including vernacular fiction. Even medical publications that originated as a form of merit accumulation could do double-duty in the realm of amateur healing: the original issuance constituted a form of healing based on the idea that performing good deeds would enable a person to accrue karmic merit, and the resulting publication when distributed and circulated could serve as a reference guide and handbook.
This polyphonic and eclectic medical landscape flourished as long as there was not a sharp and enforceable distinction between expert and layman. As Yi-Li Wu has emphasized,
Unlike today’s biomedical physician, who deploys diagnostic, and therapeutic technologies to which patients have no access, the Qing physician relied on the unassisted powers of human observation and on medicinal substances that were readily purchased in the marketplace. These resources were, in principle, also available to anyone who took the time to study their uses. Thus, the practical difference between the activities of a doctor and a layperson could be a matter of degree, not of kind.8
That medical and healing activities were as varied as the healers was not a phenomenon specific to the Qing, nor was it fully dismantled or undermined during the Republican period. But historical dynamics since the Ming such as extensive and intensive economic growth, rapid population growth, popularization of scholar-elite values among commoners, commercialization of the economy, and the rise of the “evidential research” (kaozheng) movement, which promoted rigorous philological excavation and analysis of classical texts, all became increasingly pronounced. These historical dynamics intensified the desire and debates of scholars-turned-healers to differentiate themselves from the motley crowd and assert their superiority over other types of practitioners. By the mid-Qing, expectations of securing one’s livelihood by advancing through the civil service examinations were drying up, and the number of literate men who turned to medicine instead increased to the extent that the scholar-turned-physician had become a commonplace figure in both fact and fiction. As the examination system became the primary engine for generating unemployed literati, medicine became a perfectly respectable and potentially lucrative career. Unregulated and highly commercialized, medicine could offer both status and wealth. A community of similarly trained and socially connected men emerged. They saw themselves as an intellectual community, and they strove to enhance their social status and medical authority through the production of textual materials such as medical primers, which provided pedagogic instruction to those newer to the field by establishing the normative dimensions of what counted as legitimate medical knowledge and practice, and other texts. For Qing-era physicians, scholarly formation should be understood as the prerequisite for medical competence. This did not mean that scholarly physicians were all in uniform agreement, and several competing currents of scholarly medicine vied for prestige and recognition.9 Nevertheless, working primarily in cultural terms to construct their authority, they aligned themselves with the values of the elite scholar-official class and denigrated all those who dared to practice medicine without a classical education and superior moral cultivation. To the health-seeking public, they sought to position themselves as the medical authority who could uphold standards for appropriate care and treatment. All others were likely quacks or swindlers taking advantage of a trusting public with an unfortunate, but hopefully correctable, propensity to trust folk remedies or the advice of friends over the counsel of erudite physicians.
Their criticism and complaints were largely unsuccessful in persuading medical consumers, who continued to search out all manner of medical and healing services. Successful or not, the stridency of the debate nonetheless reflected the inherent instability and contentiousness that came with attempts to define the social and cultural characteristics of who was considered a true or legitimate “physician” (yi). The arrival of Protestant medical missionaries in the mid-19th century added another potential competitor to this already quite diverse medical marketplace, although their absolute numbers (inclusive of their converts and a number of Chinese trained in Western medicine) were never numerically significant when considered in relation to the population at large. For those living in treaty ports or near missions that saw the establishment of Western medicine hospitals, dispensaries, and colleges, however, Western medicine physicians and therapies offered alternatives. They attracted Chinese patients by providing treatments for diseases that indigenous healers could not cure or did not treat, such as tumors, or by providing treatments deemed to be more effective versions of existing Chinese ones, such as those dealing with cataracts.10 Given the dynamic nature of the medical marketplace, Western medicine physicians and hospitals also adopted practices to make themselves more acceptable and appealing to the local population. Maintaining separate waiting rooms for male and female patients, employing a relatively high number of female medical personnel, and even integrating Chinese practices into their own examinations, such as palpating pulses and examining the tongue, allowed Western medicine physicians and hospitals to gain patient confidence and more securely embed themselves within local communities.11 Even with its numerically small presence, Western medicine became a more formidable competitor that came to challenge the cultural and political authority and prestige of those practicing elite, scholarly medicine.
This transformation and challenge did not derive from greater clinical or therapeutic efficacy, nor was Western medicine, as it was understood at the time and up through the second decade of the 20th century, any more systematic or institutionally or professionally consistent as its label might suggest. Instead, the key factor involved the complex ways in which it became a conduit for modernizing ideas and the extent to which Western medicine became symbolic of “a shared striving towards the ideals of modernity.”12 Protestant missionaries played a key role in disseminating knowledge of Western medicine through newspapers, journals, textbooks, and other translations. In the 1860s, this translation enterprise aligned with the self-strengthening goals of reformist Qing officials who established schools and arsenals to strengthen the empire and bolster its defenses against Western imperialism. They encouraged the dissemination of Western science and technology, which included medicine, and they often hired missionaries and other foreigners as administrators, teachers, and translators to work at these newly founded schools and arsenals. The idea that Western medicine could serve as a tool for nation-building and defending national sovereignty became even more pronounced at the beginning of the 20th century when the Qing state adopted modern epidemiological and public health measures to manage an outbreak of pneumonic plague in Manchuria in 1910–1911. Both Russia and Japan were keen to extend their territorial control into the region, and they used the outbreak of pneumonic plague, an airborne disease transmitted through person-to-person contact, to threaten Qing sovereignty if the latter failed to get the situation under control. Qing success against the pneumonic plague could not save the dynasty, however, which fell several months later, but the broader lessons that public health constituted the cornerstone of modernity and could secure or help maintain national sovereignty, and that medical modernization along Western lines was a prerequisite for national strength, were not lost.
Health in the Service of the Modern State
Health and medicine in modern China have been inextricably intertwined with the question, “what purpose should health serve?” Health and sovereignty in modern China were intertwined in such a fashion that equated a strong, autonomous nation with healthy, disciplined bodies. Individual health behaviors were linked to the status of the nation. Within this formulation, health qua public health and modernized medicine, which was sometimes elided with Western medicine and sometimes imagined as Chinese medicine modernized, was both predicated on a powerful, centralized state and served as a constructive means for state-building. State responsibility thus included preventing disease as well as minimizing or forestalling ill health. To achieve these aims, the state needed tools and mechanisms to keep track of its citizens and how they acted. It needed to build a health infrastructure that could manage the health of public spaces and citizens’ bodies. And it needed to do so in ways that signified or were meaningfully resonant to outside observers.13 These goals served as a kind of through line for much of the 20th century even as it accommodated different interpretations.
This is not to suggest that the imperial state had no interest in the health of individuals or of the population at large previously, but the scope of possible actions broadened and the underlying presumptions about the nature of political responsibility changed. The imperial state did see the people’s welfare as part of its responsibility, but the forms such responsibility took were less obviously intrusive and interventionist and tended to be tailored toward emergency situations (e.g., natural calamities such as epidemics, famine, drought, flood, and storm damage).14 The state oversaw the periodic compilation and distribution of state-sponsored medical texts. At lower levels, there was a long tradition of officials distributing medicines during epidemic outbreaks. But during the Qing, the general trend was for the central state to leave medical relief to the work of local elites (i.e., the “gentry”).15
Late Imperial and Early Republican Periods
That health and medicine became a domain for political action owed much to late 19th-century and early 20th-century political conflicts that rewrote the terms for national sovereignty and spurred a push for modernization. Chinese elites involved in the self-strengthening movement from the 1860s to the 1890s focused primarily on military and scientific technology, but medicine also had a place in their modernization program. Their efforts were deemed unsuccessful when the Qing state suffered a humiliating defeat to Japan in 1895 that resulted in the imposition of a large war indemnity and the loss of the island of Taiwan. An even larger indemnity was imposed by foreign powers on the Qing as compensation for suppressing the Boxer Uprising of 1900. Cash strapped and vulnerable to foreign predation, the Qing state undertook a period of modernizing reform known as the New Policies from 1901 to 1909.
As shocking as the defeat to Japan was, it ushered a shift in consciousness wherein a new generation of modernizers looked for guidance and instruction from the newly emergent Japanese empire, now a lodestar for Asian modernization. Japanese reforms during the Meiji period (1868–1911) were invoked as the model for China to follow when it came to military modernization, constitutional reform, education, and the teaching and regulation of science and medicine. Japan’s adoption of the technologies of modernity offered a practical blueprint for how China too could confront foreign imperialism and protect its national sovereignty. Particularly after the Qing abolished the civil service examination in 1905 as part of its New Policies, Chinese students departed for Japan to study the Western sciences, including medicine. Many of these reform-minded Chinese returned to China and became the dominant force disseminating new medical knowledge and practices and the conviction that medical modernization was essential for creating a strong and robust Chinese state.16
What modernization, let alone medical modernization, should look like in China was unclear, however, and different reformers and modernizers advanced different possibilities. One of the most important influences shaping Chinese approaches to modernization derived from Yan Fu’s (1854–1921) translations of Thomas Huxley’s writings on social Darwinism. Introduced to such principles as the “struggle for existence” and “natural selection,” Chinese reformers understood the Chinese nation as interchangeable with the Chinese race, and for one to become stronger, so too must the other in a world where only the fittest survived. For many, the key lay in building a strong and centralized state, and various governing regimes used medicine and public health to bolster their political agendas. As Ruth Rogaski has shown, these new social and political relations made manifest the semantic reorientation of weisheng, which had historically referred to a range of private, culturally sanctioned activities to “guard or protect” life that included eating habits, calisthenic exercises, and breathing practices, toward the state management of the health and hygiene of public spaces and citizens’ bodies.17 That the government should be responsible for these functions demarcated the bounds of a modern conception of state and governance, as well as new roles and expectations for the nation’s people.
Particularly in the late Qing and early Republican periods, there were many who argued for the adoption of a Japanese-style Western medical education and health care system. Japanese influence was evident in a few different ways. A large number of Japanese teachers taught in Chinese medical colleges. A 1915 survey conducted by the Rockefeller Foundation found that with only a couple of exceptions, nearly all private and public medical schools in China “were influenced by Japan and had faculty that either were educated in Japan or were Japanese professors.”18 Japanese influence could also be discerned in the Qing government’s management of public sanitation and epidemic prevention, which modeled its rules and regulations for issues ranging from medical and pharmaceutical licensing to unclear food and sanitation violations on existing Japanese laws and regulations. Implementation and enforcement of such rules and regulations were lacking, but in spirit at least Qing reformers maintained a strong conviction in the Japanese example. The first modern public health bureau, the Tianjin Provisional Government’s service de santé (weisheng bu or health service), was established by the Eight Power Allied Force in 1900 in the wake of the Boxer Uprising and was run by French and Japanese medical officers. The Republican government after 1928, in contrast, tended toward a more Anglo-American institutional model that granted health care administration its own authority rather than placing it under the jurisdiction of the police.19
Post-1927 Republican Period
Medical modernization was not limited to integrating Western medicine into the patterns of Chinese governance. The modernizing forces sweeping the country in the early 20th century also targeted Chinese medicine, but its relationship with modernization and modernity was more vexed. When juxtaposed against Western medicine, Chinese medicine was often deemed antithetical to principles and practices of modern science and representative of the corrupt and superstitious feudal culture holding back the Chinese nation. For those unwilling to simply abandon Chinese medicine to the dustbin of history or who believed that Chinese medicine had something specific and special to offer the modern world, Chinese medicine could be modernized through internal and institutional reforms. Some Chinese physicians attempted to modernize Chinese medicine by making it more scientific or systematic by rooting out internal inconsistencies. This approach sometimes involved glossing over or obscuring contradictions between different medical “classics,” diminishing the value or reinterpreting certain tenets of medical theory (e.g., Yin, Yang, and the Five Phases), or using Western medical forms such as case histories to standardize Chinese medical practice.20 Others sought to elevate Chinese medicine as an elite, scholarly discipline and high-status occupation by promoting it as part of the nationalist National Studies (guoxue) movement. Others still sought to capitalize on perceived differences between Chinese medicine and Western medicine or biomedicine and transform such differences into strengths, as was evident in attempts to incorporate germ theory into Chinese medicine and develop what has come to be known as “pattern differentiation and treatment determination” (bianzheng lunzhi).21
The critical event that led the historian Sean Hsiang-lin Lei to characterize this moment as when “Chinese medicine encountered the state” occurred in 1929 when Yu Yunxiu (1879–1954), a Western medicine physician who had trained in Japan, proposed a motion to abolish Chinese medicine at the first national conference on public health convened by the recently formed Ministry of Health. The Republican government under Chiang Kai-shek had reestablished the national government in Nanjing a year prior and for much of its tenure was an ambitious regime with a pronounced scientistic cast.22 The Ministry of Health was no exception, and its ranks were dominated by biomedical physicians. Yu’s proposal, which encountered resistance even within the government as well as more generally with the public, was unsuccessful, but it signaled the general attitude the Republican government had with respect to which medicine best suited state-led modernization.23
Given its scientistic bent and conviction that health was a part of the nation-building process, the Republican government attempted to institute state medicine as the model for the national health system.24 Within this system, Chinese medicine had no recognizable role beyond perhaps serving as a resource repository for the development of Western-style drugs.25 Under the direction of men such as Liu Ruiheng (1890–1961), Yan Fuqing (1882–1970), and Jin Baoshan (1893–1984), Chinese medical elites—many of whom were trained abroad in the United States and were connected to the Rockefeller Foundation-backed medical institution, the Peking Union Medical College—focused on building a centralized health administration that worked top-down in stages that went from urban centers down to rural villages. Central medical and research institutions were created to help train personnel as well as provide access to health laboratories at municipal and provincial levels. The Central Health Field Station (established 1931) was the technical nerve center of this national system, and it conducted a wide range of public health projects such as sanitary engineering in cities, collecting vital statistics, training maternal and child hygiene specialists, promoting health education, school health, and nutrition studies, and setting up epidemic prevention bureaus.26 At the county level, this national health administration system emphasized simple work such as epidemic prevention, basic medical service, midwifery, health education, and anti-opium smoking.27
The ambitions for a fully functioning and efficacious national health system far exceeded the Republican government’s financial capacity as well as its political will. For Chiang Kai-shek, as much as health could serve as a tool for organizing and disciplining the citizenry, his first priority lay in suppressing the Chinese communists—a task that absorbed the vast majority of the Guomindang’s human and monetary resources.28 Moreover, the Republican government delegated much of the actual work of local health construction to provincial and county governments, so the end result in terms of actual health infrastructure built and people’s access to health services was variegated, lacking uniform standards, and highly dependent on local conditions.
Post-1949 China
The establishment of the People’s Republic of China after the Communist victory in the civil war of 1945–1949 did not shift this political orientation toward state medicine, but it did alter in quite transformative ways the form and direction of state medicine pursued. The slogan that captured the general spirit in the early 1950s for national health policy was Zhongxiyi tuanjie (“unify Chinese and Western medicine”), which was a sufficiently capacious idea to accommodate different interpretations. Ideologically, the Communist leadership subscribed to a professional system patterned off that developed in the Soviet Union, which was oriented toward Western medicine and antagonistic toward anything suggestive of feudal society and its irrational superstitions. Insofar as Chinese medicine was offered state recognition and a place within the national health care system in the early 1950s, it was done so according to four guiding principles: serve the people, give priority to preventative rather than curative programs, unite Chinese medicine with Western medicine, and integrate health programs with mass movements. Doing so allowed the nascent Communist government to recruit the sizable manpower of the Chinese medicine sector—estimated at around 300,000 physicians in 1949—to administer vaccinations and provide other basic medical care.29 (For comparison, a 1935 survey indicated that the number of medical doctors registered with the Republican government was 5390, 87 percent of which were of Chinese nationality.30)
The central government’s plan to unify Chinese medicine and Western medicine was skewed in favor of the latter, at least through 1954 when red versus expert power struggles came to dominate national politics. It instituted a series of measures in 1950 and 1951 that limited the right to practice Chinese medicine to those who had graduated from a college in Republican China or passed one of the national licensing examinations that had only sporadically been offered. It organized the large-scale reeducation of practicing Chinese medicine physicians at “Chinese medicine improvement schools” (zhongyi jinjiu xuexiao) to raise their level of biomedical knowledge and political awareness. The government also urged health workers to combine mass movements with health campaigns and thereby mobilize the general population to prevent epidemic diseases and improve sanitation and hygiene. Like its predecessor, the nascent government maintained the conviction that the people’s health was essential for the formation of a strong nation, but it demonstrated far greater commitment and administrative wherewithal in integrating health work into the general economic and social reconstruction of society.
Socialist modernization included not only the building of the institutional structure of state medicine (e.g., state-run hospitals and clinics, epidemic prevention stations, maternal and child health stations in urban and rural areas), but also the political mobilization of the general population in service of both practical objectives and the formation of an embodied socialist consciousness. Even the apparent policy reversal and elevation of Chinese medicine between 1954 and 1965 cannot be separated from these terms. Mao Zedong’s overt expressions of support for Chinese medicine derived not from his belief in its clinical utility nor from a principled stance to protect and promote the development of Chinese medicine, but rather from its usefulness in ongoing political struggles.31 As Volker Scheid has described it, “In these political struggles, attitudes favoring Chinese medicine initially appear to have been nothing more than a convenient stick with which to beat the biomedical professionals dominating the Ministry of Health.”32 But even politically motivated support and opposition can produce substantive and institutional corrections and reallocations of power and resources. Following the example of the Chinese leadership, Chinese medicine was increasingly accorded value in its own right. It was accepted into the national insurance scheme and integrated into larger hospitals, which expanded its presence in the national health care system. Several new Chinese medicine colleges were formed in 1956, and the central government provided resources to develop the administrative infrastructure overseeing the research, education, and practice of Chinese medicine at both national and provincial levels. The China Academy of Chinese Medicine (Zhongguo zhongyi yanjiuyuan) was established in Beijing, which attracted eminent Chinese physicians from around the country and helped reorient and relocate Chinese medicine networks of expertise in the political center of power, Beijing, and away from Shanghai. In addition, courses were created for Western medicine doctors to familiarize and train them in Chinese medicine. By 1960, thirty-seven such courses had trained more than 2,300 physicians, while an additional 36,000 Western medicine doctors received Chinese medicine training while carrying out their medical duties—an example of the Maoist state’s attempt to integrate Chinese and Western medicine (zhongxiyi jiehe).33 In terms of the field itself, state support and incorporation of Chinese medicine into the project of socialist modernization led to the simplification, regularization, and systematization of traditional modes of practice. Some commentators have suggested that this reorganization and state involvement constituted a paradigm shift, separating traditional Chinese medicine (TCM) from the older scholarly medical tradition. The key clinical model demonstrative of this modern reorganization or “reinvention,” and which epitomizes contemporary Chinese medical practice, is bianzheng lunzhi or “pattern differentiation and treatment determination.”
Much of the medical infrastructure created after 1949 was located in urban areas, and while the creation of new medical schools and training programs helped address, to a degree, the ever-persistent problem of shortages of health personnel (especially in rural areas), attending to the medical and health needs of the rural countryside continued to pose significant challenges. The land reform campaigns and the collectivization of agriculture through the 1950s extended party control deeper into the countryside and made the introduction of commune-sponsored cooperative medical service and mass mobilization in health campaigns more feasible. Well-off and better organized communes could offer free medical service; others instituted a self-pay structure. When linked with the county hospital and mobile medical teams sent from the cities, rural cooperative medical services became better equipped to train their own health workers to provide basic medical care to farmers.34 Health campaigns targeting epidemic and endemic diseases such as schistosomiasis, filariasis, malaria, hookworm, cholera, and dysentery, and sanitation and pests such as rats, flies, mosquitos, and sparrows instilled modern ideas about health and hygiene while also physically transforming the countryside. Management of water and waste were especially important components of the rural health movement, and people were mobilized to dig wells for clean water and collect human and animal waste to be converted into fertilizers.35 The creation of the barefoot doctors (chijiao yisheng), rural youths who had received basic medical training in Chinese and Western medicines, was also motivated by concerns regarding rural access to healthcare, such that by the end of 1975 some 1.5 million barefoot doctors were engaged in rural health work.36
With Mao’s passing on September 9, 1976 and the rise of Deng Xiaoping as the paramount leader in the late 1970s, a series of ideological reevaluations and tensions took place. Medical modernization, and indeed socialist modernization (renamed “socialism with Chinese characteristics”), continued to dominate the state’s agenda, but the substance and form of these modernizations dramatically transformed as economic growth became the primary objective. Marketization and the withdrawal of the state from the direct provision of medical services dismantled the socialist health care system, and in its place, the rise of a hospital-based cash-for-service system has radically transformed the medical landscape. The state shifted its approach to social policy to one that emphasized the family as the primary welfare provider. Within this medical marketplace, no one is guaranteed basic health care, and instead patients shop for as much health care as they can afford. Rising incomes and living standards since the 1980s have likely helped ease this transition, but with greater marketization, healthcare institutions have had to take on increased responsibility of revenue generation and management. Loss of state subsidies has forced hospitals to seek other forms of financing. Newly created pricing structures have incentivized hospitals to sell medicines and technology-based services, which has also led to popular discontent about the quality of medical services and the common perception of unfairly high prices.37 New structural problems have arisen since the 1990s as access to health services has stratified by geographic and socioeconomic factors and certain epidemic and endemic diseases such as malaria and tuberculosis, which had been largely eliminated or controlled during the Maoist period, have returned in parts of China on account of lax prevention and control. Awareness of rising costs and health disparities has not escaped the central government’s attention, but its approach to date has not been to revisit past commitments and practices, but rather to expand urban insurance systems and develop a government-backed rural health insurance scheme.
National health policy continues to uphold, at least in spirit, the broad strokes of the four guiding principles set forth originally in the 1950s. The general health of the populace, especially rural health, remains a priority and a concern, but the specific means and programs to achieve health are increasingly commercialized, diversified to accommodate shifting consumer needs and demands, and specialized as medicine, Chinese and biomedical, has re-professionalized over the decades and become increasingly bound to biomedical paradigms for research (e.g., pharmaceutical research, animal experiments, clinical trials, molecular genetics) and intertwined with international pharmaceutical markets.38 Chinese medicine has not been unified with Western medicine, but medical modernization since 1949 has created a plural health system in which consumers can obtain care from Chinese medicine physicians and institutions and biomedical physicians and institutions. Chinese medicine has been provided a degree of state-sanctioned autonomy and a safe environment within which to explore, debate, and experiment with various forms of modernization. Moreover, the question, “what purpose should health serve?,” has not lessened in importance during the long 20th century and into the 21st century. Indeed, as epidemic diseases again dominate headlines and consternate people around the globe, health and medicine in modern China have proven to be an inextricable, yet defining knot tightly intertwining national identity, state power, foreign policy, and individual bodies. Nationalist prerogatives continue to shape Chinese approaches to health and medicine, but the lines supposedly separating Chinese health and world health are ever more entangled, as SARS and Covid-19 have demonstrated. As the historians Ruth Rogaski and Marta Hanson have both observed, epidemic control and international status continue to be linked in our highly socially mediated, technologically advanced world.39 That the 21st-century Chinese state is also expected to demonstrate its legitimacy through its care and management of the populace during health crises marks the ongoing links between health, medicine, and the state in a changing modern China.
Discussion of the Literature
The topic of health and medicine in China has been of longstanding scholarly interest, but one of the hallmarks distinguishing modern interest in the topic has been the separation of scholarship from practice. Although not absolute—and indeed there are a handful of practitioner-scholars who have been instrumental in rethinking the ways in which practice can open new intellectual horizons for understanding Chinese medicine—this separation has transformed the field of the history of Chinese medicine into one that is less represented by practitioner-scholars than formally trained historians.40 Given the less immediate concerns of clinical practice as well as the flourishing of cross-disciplinary synergies between history and anthropology, for example, the field has generally moved away from essentialist approaches that treat Chinese medicine as singular and bounded because it seeks to reconstruct some fundamental, unified essence of Chinese medicine and toward approaches that emphasize its pluralities, contradictions, and ever reconstructed and constructed forms.
Modern scholarly interest in Chinese health and medicine goes back to the 1920s and 1930s with the publication of Chen Bangxian’s Zhongguo yixueshi (1920) and K. Chi-min Wong and Wu Lien-teh’s History of Chinese Medicine (1932). Although these men conceived of Chinese medicine differently, the presumption that it was necessary to speak of a Chinese medicine—whether in juxtaposition to Western or scientific medicine or as an antecedent “native art” that came to incorporate, and be replaced by, medical science—gestures to the importance of the themes of nation, national identity, and modernization to the history of medicine in modern China. The style of scholarship remained fairly consistent over the course of the 20th century in China and Taiwan, but the scale of publication expanded significantly from the early 1980s onward. In China especially, greater governmental support, the training of PhDs in the field of the history of medicine in the late 1980s, and the growth of full-time researchers at institutes of the history of science and medicine have raised the discipline’s profile and brought forth a wealth of monographic studies, critical editions, translations into modern Chinese, and reference books. Anglo-American and European scholarship began coming forth from the late 1960s with Ralph C. Croizer’s Traditional Medicine in Modern China: Science, Nationalism, and the Tension of Cultural Changes playing an especially important role in shaping how historians have broached the history of Chinese medicine in modern China through a cultural nationalism lens.41 Anglo-American and European scholarship foregrounded the social, intellectual, and political contexts shaping modern Chinese thinking and attitudes toward science, health, and medicine, and such scholarship has grown tremendously in the intervening decades. Indeed, as Marta Hansen has recently observed, publications from the early 2000s to the present have collectively brought “the field of medicine in China to a new level of synthesis” by demonstrating “how integral the history of medicine and public health is to Chinese history” while at the same time facilitating the integration of East Asian medical history into more broadly conceived global histories of health and medicine.42
One can observe two general features about scholarship on health and medicine in modern China. First, recent scholarship has increasingly foregrounded specific continuities across time periods such that even as scholars may continue to work within bounded time periods (e.g., late imperial, Republican, Mao-era, post-1976 PRC), their work highlights the importance of seeing connections and continuities across the 1911, 1949, or 1976 divides. This is especially evident in scholarship that has examined modern transformations of Chinese medicine from 19th-century missionaries through the PRC period and how medicine became intertwined with the modern state. Scholars have explored the ways in which medicine and public health served as critical sites for negotiating and protecting national sovereignty and furthering nation-building initiatives.43 Some have examined the epistemological reconfigurations of Chinese medical knowledge resulting from “encounters” with the state, as well as the shifting cultural terrain of meanings and practices constituting modern health and hygiene.44 Others have investigated Sino-Western medical politics during the Republican period, 20th-century medical and health transitions, and the role of diasporic Chinese in developing public health and medicine.45
The second characteristic is the increased specialization and diversification of topics investigated. One area of research that has grown in importance concerns gender and sexuality, with scholars focusing attention on the role of gender and sexuality in shaping both state programs and policies, popular experience, and new subjectivities.46 Other areas of research include mental health, psychiatric institutionalization, and identity formation;47 medical subdisciplines such as immunology, forensic medicine, and nutrition science;48 social histories of material objects such as tobacco and its intersections with gender and global public health;49 patient experiences;50 and histories of disease or disease concepts over the longue durée as well as with regard to surveillance, control, and eradication.51
One further comment should be made about existing literature on the history of health and medicine in modern China. Recent scholarship has increasingly paid greater attention to unpacking the global within histories of health and medicine in China and China within global histories of health and medicine. Here, the emphasis is less on how China responded to the introduction of new ideas and practices than on how local developments were often already implicated and dependent on the global circulation of knowledge and material objects. The emphasis here has been on excavating the global genealogies of scientific practices in interaction with highly local situations. Existing scholarship can be divided into (roughly) histories of medicine and histories of public health, and for the latter category, this emphasis on the global has been more pronounced.52 Thus, in addition to works focusing on specific national contexts, scholars have also tackled regional developments, imperialist medical legacies, and epidemics.53
