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Health Policy During the Great Leap Forward

  • David M. Lampton

Heretofore, analysts have argued that one characteristic of mobilization in China is to provide uniformity in policy direction. This paper sets out to demonstrate that, in at least the public health area, a diverse set of public policies was pursued even in a period as apparently “radical” as the Great Leap Forward (1958–60). The reason for this policy diversity is that different segments of health policy were made in different political arenas, or institutional settings; the pressures, perceptions and resources which characterized one of these political arenas did not necessarily characterize another. The “failures” of the Leap did not simply arise from a ubiquitous “radical” assertion of power but, on the contrary, resulted from the inconsistencies in leadership and programme characteristic of diverse policy-making arenas. Because policy-making responsibility is divided among political arenas, political bargaining and conflict have characterized the allocation to them of different health issues; elaborate strategies have been devised by organizations in order to acquire and /or hold certain areas of policy and unburden themselves of others.

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1. For an excellent theoretical treatment of political arenas, see Swartz, Marc J., Local Level Politics (Chicago: Aldine, 1968), pp. 146.

2. Lindblom, Charles E., The Intelligence of Democracy (New York: Free Press, 1965). This study provides an excellent analysis of problems of policy co-ordination and discusses “hierarchical” and “partisan mutual bargaining” as two pure types of policy-making organization.

3. “Speech made by Chairman Mao at a standing committee meeting of the Central Committee” (Spring 1955). Hsin jen wei (New People's Health) (Peking: People's Health Press, 1967), p. 9.

4. Vogel, Ezra, Interview No. 12, p. 1. I would like to thank Professor Vogel for making his unpublished interview protocols available to me. The interview numbers were assigned by me.

5. Skinner, G. William and Winckler, Edwin, “Compliance succession in rural Communist China: a cyclical theory,” in Etzioni, Amitai (ed.), A Sociological Reader on Complex Organizations (New York: Holt, Rinehart, and Winston, 1969), pp. 410–38.

6. Cited in Thoroughly criticize and repudiate the eight year medical education program pushed by China's Khrushchev,” China's Medicine, No. 3 (1968), pp. 164–65.

7. Lampton, David M., “The Politics of Public Health in China: 1949–1969,” Stanford University Ph.D. Dissertation, 1974, pp. 159–66; also, Cheng, Chu-yuan, “Health manpower in China,” paper presented at the Macy Foundation Conference on Public Health in China, Ann Arbor, Michigan, 05 1972.

8. “Thoroughly criticize and repudiate the eight year medical education program;” also, Russell, Maud, “Medicine and public health in the People's Republic of China,” Far East Reporter (n.d), pp. 1213.

9. En-lai, Chou, “Report on Government work,” (18 04 1959), Current Background (CB), No. 559, pp. 1617.

10. The operational definition of “exotic” research is slippery in many cases, but “exotic” articles deal with problems that are (a) relatively rare, (b) require elaborate and costly treatment which only a few specialists can accomplish, and (c) are of greater concern to the international medical community than the immediate clinical needs of China. The usual “exotic” research article begins by stating, “While we have only seen four cases of this problem in the last ten years, it is intrinsically interesting because.…” Since the categories are loose, however, the margin of “error” in the content analysis is substantial.

11. In this discussion of the sequence of national level meetings we are fortunate in having recently acquired a compendium of Mao's speeches at these gatherings. Mao Tse-tung ssu-hsiang wan-sui (Long Live the Thought of Mao Tse-tung) (n.p., 1969). For English language data on these meetings, see Chang, Parris, “Research notes on the changing loci of decision in the Chinese Communist Party,” The China Quarterly (CQ), No. 44 (1970), pp. 169–94.

12. Tse-tung, Mao, “Tsai pa-chieh liu-chung ch'üan-hui shang te chiang-hua” (“Speech at the Sixth Plenum of the Eighth Central Committee”), Mao Tse-tung ssu-hsiang wan-sui, pp. 259–69.

13. See, for example, Horn, JoshuaAway With All Pests (New York: Monthly Review Press, 1969), Chapter 11. An ambiguity arises in our discussion of burn research and the rejoining of severed limbs. Certainly the treatment of these two traumatic problems is expensive, requires large capital investments, and the rate of recovery to the point that the individual is once again productive is low. In a society with as few resources as China a real question arises as to whether or not this is the optimal investment of each health yüan. On the other hand, because China is at a relatively early stage of industrialization, burns and traumatic amputations are extremely common. The Chinese argue, however, that restoring one worker to a productive life makes the costs worthwhile.

14. Te-ch'uan, Li, “Placing health undertakings at the service of production,” CB, No. 577, p. 20. Minister Li delivered this address to the first session of the Second National People's Congress, April 1959.

15. Lampton, “The Politics of Public Health,” Chapters IV and V.

16. Teh-hua, Li and Min-ting, Yang. “The planning of Ch'ingpu hsien and Hung Ch'i people's commune,” CB, No. 544, pp. 111.

17. “An investigation report on how the Ch'ünhsing brigade in Ch'üchiang hsien, Kuangtung province firmly adheres to co-operative medical service over the past eleven years,” in Selections from China Mainland Magazines (SCMM) (Hong Kong), No. 642, p. 30.

18. Vogel, , Interview No. 2, p. 1.

19. “Sectional medical service adopted in over thirty cities,” Jen-min jih-pao (People's Daily), 22 10 1957, in Survey of China Mainland Press (SCMP) (Hong Kong), No. 1645, p. 19.

20. The analysis thus far suggests a conflict which has been crucial in understanding the evolution of health care policy; the conflict of interest between the hsien hospital and the commune health authorities. The commune authorities find it in their interest to refer as many patients as possible to the county hospital and then balk at paying for them. The county, on the other hand, attempts to restrict access and insure payment before admittance is granted. As one interviewee said: “Communes are theoretically supposed to pay for the workers [peasants] to go to the county hospital but there has been a lot of difficulty in getting money out of the communes and county hospitals have lost a lot of money by treating commune patients.” Vogel, , Interview No. 30, p. 5.

21. “An investigation report,” SCMM, No. 642, p. 28; also Jen-min jih-pao, 7 December 1968.

22. “Co-operative medical system in Honao,” Jen-min jih-pao, 24 September 1958.

23. Yun-pei, Hsu, Chinese Medical Journal, 80, No. 5 (1960), p. 413; also, Piao, Ho, “Health units should have the aiding of agriculture as their first duty,” Hung-ch'i (Red Flag), No. 18 (1960), pp. 1220.

24. David M. Lampton, “The struggle for health: group politics in China,” footnote 19. This paper was presented at Hong Kong University, 13 January 1973, at a seminar on “Ideology and Organisation.” It is often asserted that health charges are so low that they do not really constitute a burden. This would seem not to be the case for the simple reason that people actually “invaded” hospitals during the Cultural Revolution demanding that they receive the same benefits as those who were insured. If a patient was not insured, he had to pay a deposit before admittance. Finally, even low daily charges add up if one is stricken with a chronic or long-term illness. While data are scarce, one article noted that when typhoid struck one man's family, its cure cost 970 yüan. See SCMM, No. 642, p. 31.

25. Donnithorne, Audrey, China's Economic System (London: Allen and Unwin, 1967), p. 213.

26. Kallgren, Joyce, “Social welfare and China's industrial workers,” Barnett, A. Doak (ed.), Chinese Communist Politics in Action (Seattle: University of Washington Press, 1969), pp. 540–73. Kallgren shows how resource constraints affected all areas of welfare policy; “need” is one of several criteria for determining who shall be given benefits.

27. Wen-hui pao, 10 March 1959, noted that 30,000 people had learned the art of acupuncture in a mass movement.

28. Croizier, Ralph, Traditional Medicine in Modern China (Cambridge: Harvard Unversity Press, 1968), p. 187.

29. Kuo-chang, Huang et al. , “A few problems in health work,” Hei-lung-chiang jih-pao (Hei-lung-chiang Daily), 7 06 1957.

30. Recent achievements in the promotion of traditional Chinese medicine,” Chinese Medical Journal, 78, No. 2 (1959), p. 103.

31. “Earnest implementation of the Party's policy on traditional medicine,” Jen-min jih-pao, 25 January 1959; also Chinese Medical Journal, 78, No. 3 (1959).

32. “A few problems in the research of Chinese medicine,” Chien-k'ang pao (Health Bulletin), 29 January 1957. Chien-k'ang pao was published by the Ministry of Public Health and was not in circulation outside China. Union Research Institute, however, has a limited run of this periodical on microfilm covering, primarily, the year 1957.

33. Jen-min jih-pao, 10 March 1959.

34. Kuang-ming jih-pao (Bright Daily), 14 December 1956.

35. Hsin-chung, Ch'ien, “Summing up of mass technical experiences with a view to expediting eradication of the five major parasitic diseases,” Chinese Medical Journal, 77, No. 6 (1958), p. 522. This article noted that 400,000 people were treated in 1956 and 500,000 in 1957. Originally it had been projected that 12 million would be treated in 1957, but this did not occur.

36. A great victory for Mao Tse-tung's thought in the battle against schistosomiasis,” China's Medicine, No. 10 (1968), p. 594.

37. Jen-min jih-pao, 16 May 1958.

38. All China Conference on Parasitic Diseases,” Chinese Medical Journal, 77, No. 6 (1958), pp. 519–20.

39. Ibid.

40. Horn, , Away with All Pests, pp. 94106. Horn describes the military atmosphere of the anti-parasite campaigns.

41. Huei-han, Li, “Prevention and treatment of filariasis in Shantung province,” Chinese Medical Journal, 78, No. 1 (1959), p. 54.

42. The historical record is replete with specific instructions from Mao on health work. Hsin en wei has a list of Mao's major statements and directives. In addition, Translations on Communist China, 90, Joint Publications Research Service (JPRS) (Washington D.C.) No. 49826, 12 02 1970, p. 24, has a complete translation of Mao's statement of 25 June condemning the Weishengpu.

43. Piao, Ho, “Speech to the National Hospital Work Conference,” 28 03 1958, Hsin-hua pan-yüeh-k'an (New China Semi-monthly), No. 128, pp. 143–48. This summarizes Premier Chou's speech to the Third Plenum on health care.

44. En-lai, Chou, “Report on government work,” pp. 1617.

45. Te-ch'uan, Li, “The new tasks for the protection of public health,” New China News Agency (NCNA), 16 06 1956, in CB, No. 405, p. 12.

46. Ibid.

47. Hsin-chung, Ch'ien, “Summing up of mass technical experiences,” p. 527.

48. Mao, bitterly criticized the Weishengpu in 04 1953 with “Instructions concerning the examination of leadership work of health departments of Military Committees”; in July 1954 with “National Higher Medical Education Conference”; and in the Spring of 1955 with a speech at a standing committee meeting. All statements can be found in Hsin jen wei, pp. 6–9.

49. Ch'eng, Ho, “An Investigation of my incorrect thought in health work,” Jen-min jih-pao, 19 11 1955.

50. Nan-fang jih-pao (Southern Daily), 19 May 1955.

51. Schurmann, Franz, Ideology and Organisation in Communist China (Berkeley: University of California Press, 1968), p. 190. “Vertical rule reached a high point around 1954. Not only the major economic, but other Ministries as well, had created nation-wide networks of organisation.”

52. Of course, we have the “Resolution of the Chinese Communist Party concerning the question of establishing rural People's Communes” (“Chung-kung chung-yang kuan-yü tsai nung-ts'un chien-li jen-min kung-she wen-t'i te chüeh-yi”), 20 August 1958, Jen-min shou-ts'e 1959 (People's Handbook) (Peking: Takung pao she, 1959), pp. 3233. This document tells what the decision was, not what the inputs to that decision were. Also the generally comprehensive Mao Tse-tung ssu-hsiang wan-sui does not have Mao's speech(es) dealing with this meeting.

53. Ch'üan-wu-ti (Invincible), No. 17. This series of newspapers is held by Union Research Institute in Hong Kong. It was published by the Chien-k'angpao Yenan commune in Peking during 1967.

54. Te-hua, Li and Min-ting, Yang, “The planning of Ch'ingpu hsien and Hung-ch'i people's commune,” pp. 111.

55. Hsien-nien, Li, “Speech to the 5th session of the First NPC,” CB, No. 493, p. 13.

56. Skinner, G. William, “Marketing and social structure in rural China,” Part III, Journal of Asian Studies, 24, No. 3 (1965), p. 384.

57. Solomon, Richard, Mao's Revolution and the Chinese Political Culture (Berkeley: University of California Press, 1971).

58. Lewis, John Wilson, Leadership in Communist China (Ithaca: Cornell University Press, 1963).

59. Of the eight vice-ministers of health, five were medical doctors: Dr Fu Lien-chang, Dr Su Ching-kuam, Dr Ch'ien Hsin-chung, Dr Ho Piao and Dr Tsui I-t'ien. Hsu Yun-pei, Chang Kai and Wu Yun-fu were not medical doctors nor did they have a medical background. While it is not a sound practice to try to measure intra-Party influence just by counting noses, the structure of the Ministry gave each vice-minister a functional area of responsibility which meant that he had a bureaucratic base of power. Also, it is clear from the kinds of policies which the Ministry proposed and carried out that the political cadres did not, in every instance, overwhelm the professionally oriented vice-ministers. For more detail on the backgrounds of each of these individuals see, Lampton, “The Politics of Public Health.”

60. Drs Su Ching-kuan, Fu Lien-chang, probably Tsui I-t'ien, Ch'ien Hsinchung and perhaps Ho Piao, had all held responsible positions in the PLA medical corps.

61. Dr Ho Piao (north-west region), Dr Tsui I-t'ien (east China region), and Ch'ien Hsin-chung (south-west region) had all been in charge of regional health bureaux before their elevation to Peking.

62. Jen-min jih-pao, 28 March 1953.

63. Tse-tung, Mao, “Instructions concerning examination of leadership work of health departments of Military Committees,” (04 1953), Hsien jen wei, pp. 67.

64. Vogel, , Interview No. 42, p. 14.

65. It is of course apparent that the leaders of an organization as internally complex as the Weishengpu cannot be said to share values on all issues at all times nor to order those values in the same way. However, it is equally apparent that in comparing the values of Weishengpu leaders to those of Commune Party Committee members, for instance, there is a characteristic perspective of Weishengpu leaders that derives from their roles and training.

66. MacFarquhar, Roderick, The Hundred Flowers (London: Stevens, 1960).

67. Jen min jih-pao, 6 October 1956, cited in MacFarquhar, , The Hundred Flowers, p. 127.

68. Chien-k'ang pao, 18 January 1957.

69. Chien-k'ang pao, 7 May 1957.

70. Kuang, Sun, “Urban population must be controlled,” Jen-min jih-pao, 27 11 1957, SCMP, No. 1668, p. 7; see also, Vogel, Ezra, Canton under Communism (Cambridge: Harvard University Press, 1969), p. 259. Vogel notes: “In 1958 there were 100,000 new jobs in Canton alone and over a million people migrated to urban areas of Kwangtung to take advantage of new economic opportunities.”

71. Chien-Kang pao, 7 May 1957.

72. Chien-k'ang pao, 23 April 1957.

73. “Grave waste in free medical care,” Jen-min jih-pao, 17 April 1955.

74. Ibid.

75. “The phenomenon of waste is serious,” Kuang-ming jih-pao, 22 June 1955.

76. Health expenditures were lower in 1956 than they were in 1953. The Ministry's revenue base was not expanding nearly as rapidly as its responsibilities and, in fact, the proposed health budget of 1958 was smaller than that of 1957. See Chen, Nai-ruenn, Chinese Economic Statistics (Chicago: Aldine, 1967) p. 446.

77. Mao Tse-tung, “Lun shih ta kuan-hsi” (“On the ten great relationships”), Mao Tse-tung ssu-hsiang wan-sui.

78. “Balanced,” in the present context, means balanced between light and heavy industry, between agriculture and industry, and a more even geographical dispersion of industry between, the coastal and inland counties.

79. Tse-tung, Mao. “On the correct handling of contradictions among the people,” in Selected Readings From the Works of Mao Tse-tung (Peking: Foreign Languages Press, 1971), p. 476.

80. NCNA, 14 May 1957, cited in MacFarquhar, , The Hundred Flowers, p. 233.

81. Donnithorne, , China's Economic System, p. 213. See also, Lampton, “The Struggle for Health,” footnotes 19 and 20.

82. NCNA, 14 May 1957, cited in MacFarquhar, , The Hundred Flowers, p. 234.

83. Kuang, Sun, “Urban population must be controlled,” pp. 37.

84. Tse-tung, Mao, “Preface to the socialist upsurge in China's countryside” (27 12 1955), SCMM (Supplement), No. 22, p. 10.

85. Tse-tung, Mao, “Tsai Ch'eng-tu hui-yi shang te chiang-hua” (“Speech at the Ch'engtu meeting”) Mao Tse-tung ssu-hsiang wan-sui, p. 161. Speech given on 10 March 1958.

86. Thorough prevention and cure of schistosomiasis,” Jen-min jih-pao, 22 01 1957, SCMP, No. 1473, p. 15.

87. Schumann, Ideology and Organization, pp. 193–94.

88. Jen-min jih-pao, 16 May 1958.

89. Tse-tung, Mao, “Farewell to the God of Plagues,” in Ch'en, Jerome, Mao and the Chinese Revolution (London: Oxford University Press, 1965), p. 349.

90. Skinner, , “Marketing and social structure,” pp. 386 and 389. Skinner notes that the sizes of communes were highly variable. “The territory encompassed by the average commune of non-agricultural China was, therefore, immense: something in excess of 1,800 square kilometers. By contrast, the approximately 21,600 communes within agricultural China averaged less than 200 square kilometers in size.”

91. Oksenberg, Michel, “Chinese politics and the public health issue,” Bowers, John Z. and Purcell, Elizabeth, Medicine and Society in China (New York: The Josiah Macy, Jr Foundation, 1974), pp. 149–54.

92. Donnithorne, , China's Economic System, pp. 6667.

93. Te-hua, Li and Min-ting, Yang, “The planning of Ch'ingpu hsien,” p. 1.

94. Vogel, , Canton under Communism, p. 233.

95. The fact that severely discouraging effects resulted from free health care, and other welfare benefits, is demonstrated by the fact that the Sixty Articles on Agriculture specifically rejected “equalization.” As one Chinese summary of the Sixty Articles said (April 1961): “We have always opposed equalization, for it denies the difference in income and distribution between teams and between commune members. And the denial of this distinction is a denial of the Socialist principle ‘to each according to his work, and the more work the more pay.’ If we do not exactly solve this problem, we will not be able to mobilize fully the productive positivism of the masses in general.” See Cheng, Chester (ed.), Kung-tso t'ung-hsün (The Bulletin of Activities) (Stanford: Hoover Institution Press, 1966), p. 527.

96. Cited in Skinner, , “Marketing and social structure,” p. 397.

97. Ibid.

98. The Mao-Liu controversy over rural public health,” Current Scene, 7, No. 2 (1969); see also, Lampton “The Politics of Public Health,” Chapter IV.

99. The commune or the production brigade?,” Jen-min jih-pao, 4 01 1969, CB, No. 872, p. 31. This article describes the conflict in one commune over the question of at which level health centres should be run.

100. An investigation on how Ch'ünhsing brigade in Ch'iichiang hsien Kuangtung province firmly adheres to co-operative medical service over the past eleven years,” Hung-ch'i, No. 1 (1969), SCMM, No. 642, p. 31. This article details the argument between brigades and teams over who should control brigade enterprises. As one person in one production team said, “If the enterprises aren't turned over [to the production teams] it means that brigade cadres are corrupt”

101. Ch'üan-wu-ti, No. 14, p. 2.

102. En-lai, Chou, “Report on government work,” pp. 1617.

103. Kuei-chou jih-pao, 29 July 1956.

104. “Do a good job in industrial health work,” Nan-fang jih-pao (Southern Daily), 28 November 1955. This article promotes the idea that all the organizations related to industrial and labour work have a responsibility for industrial safety. Recent visitors to China have noted the apparently high rate of industrial accidents. The great interest in burn research and the rejoining of severed limbs would tend to confirm this. If this is the case, it would indicate that efforts to get inter-Ministry co-operation have been less than totally successful and that the need for increased production is in conflict with the expenditure of resources on industrial safety and health; see also, David M. Lampton, Interview File 21K (unpublished).

105. Almond, Gabriel and Powell, Bingham, Comparative Politics: A Developmental Approach (Boston: Little, Brown, 1966), pp. 201203.

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