The Triumph Of Praticalty Tradition And Modernity In Health Care Utilization In Selected Asian Countries Stella R Quah Editor

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The Triumph of Practicality

The Institute of Southeast Asian Studies was established as an
autonomous orgamzat10n m May 1968. It IS a reg10nal research centre
for scholars and other spectaltsts concerned w1th modern Southeast
Asta, particularly the multdaceted problems of stab1hty and secunty,
economiC development, and poltttcal and sooal change.
The Institute IS governed by a twenty-two-member Board of Trustees
compnsmg nommees from the Smgapore Government, the National
Umvers1ty of Smgapore, the vanous Chambers of Commerce, and profes-
Sional
and
c1v1c orgamzat1ons. A ten-man Executive Committee oversees
day-to-day operations; It IS cha1red by the Director, the Institute's ch1ef
academic and admm1strat1ve off1cer.
The Social Issues in Southeast Asia (SISEA) programme was estab-
ltshed at the Institute m 1986. It addresses Itself to the study of the
nature and dynamics of ethmc1ty, rehg1on~, urbamsm, and population
change m Southeast Asta. These Issues are exammed w1th particular
attention to the lmphcatlon» for, and relevance to, an under,tandmg
of problems of development and of societal confltct and co-operation.
SISEA IS gutded by a Regional Adv1,ory Board compnsmg semor scholars
from the vanous Southeast As1an countnes. At the Institute, SISEA
c~me~ under the overall charge of the D1rector wh1le Its day-to-day run-
mng IS the responslblhty of the Co-ordmator.

The
Triumph of Practicality
TRADITION AND MODERNITY IN
HEALTH CARE UTILIZATION
IN SELECTED ASIAN COUNTRIES
Edited by
STELLA R. QUAH
National University of Singapore
I~BI!! Social Issues in Southeast Asia
&&lliiil INSTITUTE OF SOUTHEAST ASIAN STUDIES

Pubhshed by
Insntute of Southeast Asian Studies
Heng Mui Keng Terrace
Pasir PanJang
Smgapore 0511
All nghts reserved
No part of thi; puhhcanon may be reproduced, stored m a retneval system, or
transmitted m any form or by any means, electronic, mechanical, photocopymg,
recordmg or otherwise, without the pnor permission of the Institute of Southeast
Asian Studies.
© I989 Institute of Southeast Asian Studies
Cataloguing in Publication Data
The Tnumph of pracncahty tradition and modernity m health care utilization
m selected A,wn countnes I edited by Stella R Quah.
1 Medical care--Asia--Unhzanon--Collected works
2 Folk medicine--Asia--Collected works
I Quah, Stella R
1l Institute of Southeast Astan Studie; (Smgapore)
RA303 T84 1989
ISBN 981-3035-19-6
The re,ponsihthty for facts and opmions expressed m tht' publtcatton re,ts exclu;tvelv
wtth the authors and thetr Interpretations do not nece,sanly reflect the vtcws or
the pohcy of the Institute or tts supporter'
Tvpeset b:v The Fototype Busmess
Pnnted m Srngapore by Krn Keong Pnntmg Co Pte Ltd

List of Tables
List of Figures
Contributors
Preface
Contents
The Triumph of Practicality
Stella R. Quah
2 Marriage of Convenience: Traditional and Modern Medicine
in the People's Republic of China
vii
X
xii
XV
Stella R. Quah and Li ]ing-wei 19
3 Traditional and Modern Medicine in Japan: Main Features
Kyoichi Sonoda 4 3

Vl Contents
4 Stress-Copmg and T radmonal Health Care Utthzation
m Japan
Tsunetsugu Munakata 75
5 Receptlvtty to Tradtttonal Chmese and Modern Medtcme
among Chinese Adolescents m Hong Kong
Rance PL. Lee and Yuet-wah Cheung 101
6 The Best Bargam: Medical Opttons m Smgapore
Stella R. Quah 122
7 Unhzatton ofT radltlonal and Modern Health Care Servtces
m
Thatland
Santhat Sermsn
160
8 Confirmmg the T numph of Practtcahty
Stella R Quah 180

List of Tables
1.1 Companson of lndrcators of Development of
F1ve Selected Countnes 14
2.1 Tradltlonal and Modern Health Serv1ces m Chma,
1949, 1981, and 1985~86 29
3.1 Numbers and Rat1os of Modern Medrcal Personnel
m Japan, 1972~84 45
3.2 lnst1tut1ons Trainmg Modern Medrcal Personnel, 1986 46
3.3 Numbers and Ranos of Four Types of Tradltlonal Medrcme
Practitioners m Japan, 1972~84 48
3.4
lnst1tut1ons Trammg Tradltlonal
Medrcme Pract!tloners, 1986 49
3.5 Cost of Production of Modern and Trad1t1onal
Med1cmes, 1982~84 51

urr
3.6
3.7
3.8
3.9
3.10
3.11
A3.1
A3.2
A3.3
4.1
4.2
5.1
5.2
5.3
5.4
5.5
6.1
Trends m Production of Prescnbed and Non-Prescnbed
Herbal
MediCmes, 1976-84
Unltzatton of Modern and T radltlonal MediCal
Resources for Selected Health Problems, Japan, 1985
Utiltzanon of Modern and Tradltlonal MediCal
Resources by Sex and Age, Japan, 1985
Utilization of Modern and Trad1t10nal Medical
Resources by
Urban and Rural Sectors, Japan, 1985
Trends m
Unltzatlon of Modern and Tradltlonal
MediCal Resources, Japan, 1955-85
Unhzanon of Traditional Medtcme, Bunkyo Study, 1986
Unlization of Thirteen Types of Tradltlonal MediCal
Resources by Respondents' Sex, Age, and Educational
Level,
Bunkyo Study, 1986
Opmions on
Kanpo (Tradlt!onal Chmese Medtcme)
by Respondents' Sex, Age,
and Educational Level,
Bunkyo Study, 1986
Acnon Taken When Affected by Two Health Problems,
by
Respondents' Sex, Age, and Educational Level,
Bunkyo Study, 1986
Effectiveness
of Instrumental Support and
Emotional Support
Correlation and Mulnple Regresston Analysts on the
Psycho-Soctal Background of Folk Remedtes Unltzatton
m the Population of Tokyo Suburbs
AssoCiation between Each SoClo-Demographtc Factor
and the Use of Chmese or Western Medtcal Care
Evaluation of Chmese versus Western MediCal Care
Assocwtton between Each SoClo-Demographtc Factor
and the Evaluation of Chinese versus Western
Medical
Care
Evaluation on Dtsease Treatment by
Reltgton and
Mother's Level of Education
Evaluation
on
Tome Care by Sex, Age, and Father's
Occupational Status
Modern Medical Servtces m Smgaporc, 1978 and 1986
52
54
56
58
59
61
64
71
72
79
94
108
110
112
112
114
125

Ltst of Tahb lX
6.2 Utthzanon of Modern Health Servtces m the Pub he Sector:
Pattent Attendance, 1978 and 1986 139
6.3 Utthzatton of Tradtttonal Chmese Medtcme: Clime
Attendance,
1978 and 1986 142
6.4 Companson of
Unhzanon of Modern and Tradltlonal
Health Servtces, 1978 and 1986 144
6.5 Four Most Common Types of Condltlons Treated by
Modern
and Tradttional Health
Scrvtces, 1976-86 149
7.1 Government Health Servtce Facthttes m Thatland, 1978 167
7.2 Health Servtces Utthzanon m Thatland, 1970 168
7.3 Number of Government Health Servtce Faolltles m
Thatland, 1970, 1981, and 1987 171
7.4 Health Servtces Utthzatton m Thatland, 1979 and 1985 174

List of Figures
2.1 Orgamzatlon of National Health Services 27
2.2 Three-Tier Network of Health Services in Rural China 28
2.3
Departments and Orgamzatlons under the
Mmistry of
Pubhc Health, Chma, 1982 37
2.4
The Academy of Tradltlonal Chmese
Medicme, Chma,
1982 39
4.1 Trends m
the Rates for
Receivmg MediCal Care for
Mam Illnesses 77
7.1 Relationship Patterns of Modern and Tradltlonal Health
Practitioners and Patients 165
7.2
An
Expansion of Government and Modern Health
ServiCes to the Population 172

Lrst of Frgure1
8.1 Influence of Pragmatic Acculturation and Access1b1hty
of Modern Med1cal Servtces upon Dual Usage of
Xl
Medical Resources 187

Contributors
Yuet-wah Cheung, Ph.D., IS a Lecturer m the Department of Sociology
at the Chmese Umvers1ty of Hong Kong. H1s areas of spec1altzat10n are
med1cal soc1ology
and sooology of dev1ance. He has
pub!tshed numerous
arttcles m professional mternat1onal JOurnals such as Sacral Sczence &
Medzcme, Human Organzzatwn, Canadzan Cnmmology Forum, Socwlogzcal
Focus, Medzcal Anthropology, Revzews m Anthropology, Aszan Profzle, and
the Internatwnal Journal of Comparative and Applzed Cnminal ]ustzce,
and contnbuted a number of chapters m books. His recent publication
1s Mzsswnary Medzcme m Chma A Study of Two Canadzan Protestant
Mzsswns
m
Chma before 1937 (Lanham, Maryland: Umvers1ty Press of
Amenca, 1988).

Contnbutors xm
Rance P.L. Lee, Ph.D., Is Profe~sor of Sociology, Dean of the Faculty of
Sacral Science~, Chmese Umversity of Hong Kong; Director of the In-
stitute of Sooal Studies of the Chmese Umversity of Hong Kong; and
Secretary-Treasurer of the Research Committee on the Sociology of Health,
International Sociological Association. His maJor areas of research mclude
interaction between tradltlonal and modern health care systems, problems
of high-density livmg, and stress-copmg strategies m Chinese culture. He
has contnbuted over seventy papers in academtc Journals and as chapters
m books. He Is also the author of many books, among whtch are Hong
Kong Economtc, Socwl and Polmcal Studtes m Development (New York:
M.E.
Sharpe, 1979);
Sacral Ltfe and Development m Hong Kong (Hong
Kong: Chinese Umversity Press, 1981); The People's Commune and Rural
Development
(m Chmese) (Hong Kong: Chmese
Umversity Press, 1981);
and Stattsttcal Analysts m Socwl Research (m Chmese) (Wubei, Chma:
People's Press, 1987); and the editor of Corruptwn and Irs Control m Hong
Kong (Hong Kong: Chmese Umversity Press, 1981).
Li Jing-wei IS Professor and Director of the Chma Institute of Medical
History and Medtcal Literature, Chma Academy of Traditional Chmese
Medtcme; Deputy Director of the Sooety of History of Medtcme, Chmese
Medical Assoctation; and Council Member of the Chinese Sooety of
History of Science and Technology. His research mterests cover vanous
aspects of the history of tradltlonal Chmese medicme, and he has wntten
extensively on the history of Chmese medtcme. He IS the chief editor
of "Fascicle on Medical History", Encyclopaedw of Tradmonal Chmese
Medtcme (m Chmese) and Dtctwnary of Htstoncal Ftgures of Tradttwnal
Chmese Medtcme (m Chmese); and co-author of A Complete Dtctwnar::.'
of Tradttwnal Chmese Medtcme (m Chinese).
Tsunetsugu Munakata, Ph.D., Is Director of the Division of Society
and Culture Research, National Institute of Mental Health, Japan. His
research mterests mclude medical sociology, health psychology, and trans-
cultural analysis. He Is the author of, among many publications, Setshm
Iryo no Shakmgaku [Sociology of mental health treatment] (Tokyo: Kou-
bundo, 1984) and Koudoukagaku kara Mtta Kenko to Byokt [Behavioural
science of health and Illness] (Tokyo: Medical Fnend Co., 1987); and

XlV Contnbutors
the co-author (with T.S. Lebra et al.) of Japanese Culture and Behavwr,
rev. ed. (Honolulu: Umvers1ty of Hawau Press, 1986).
Stella R. Quah, Ph. D., 1s a Semor Lecturer m the Department of
Sociology at the National University of Smgapore and Vice Chairperson
of the Research Committee on the SoCiology of Health, International
SoCiological AssoCiation. She has published papers m professional inter-
national Journals and chapters m books in the areas of soc1al policy,
medical soc10logy, and sociOlogy of the fam1ly. Among her publications
are Balancing Autonomy and Control: The Case of Professwnals m Smgapore
(Cambridge: Center ·for InternatiOnal Studies, Massachusetts Institute
of Technology, 1984) and Between Two Worlds. Modern Wwes in a Tradi-
twnal Settmg (Singapore: Institute of Southeast As1an Studies, 1988).
She 1s the co-author (w1th Jon S.T. Quah) of Fnends in Blue: The Pollee
and the Publrc in Smgapore (Smgapore: Oxford University Press, 1987)
and the co-comp1ler (with Jon ST. Quah) of Smgapore (Oxford: CLIO
Press, 1988).
Santhat Sermsri, Ph.D., 1s Associate Professor and Dean of the Faculty
of SoCial Sciences and Humamtles, Mah1dol Umversity, Bangkok, Thm-
land; and Board Member of the ASEAN Trammg Center for Primary
Health Care Development m Bangkok. H1s research interests include
health serviCes utilization, soc1al1mpact of health, and social demography.
He is the co-author (with J.N. R1ley) of The Vanegated Thaz Medzcal System
as a Context for Brrth Control Servzces (Bangkok: Institute for Population
and SoCial Research, 1974); and the author of Impact of Rapid Urbaniza-
twn on Health Status zn Thailand (Bangkok: Project of Applied Soc1al
Sciences
to the Development of Population Activities and Family
Plan-
nmg, Mah1dol Umversity, 1986).
Kyoichi Sonoda, Ph.D., 1s Professor of SociOlogy in the School of
Health Snences, Faculty of Med1cme at the University of Tokyo. He has
published numerous papers on health and 1llness behaviour and attitudes
m Japan,
includmg the
utilization of health services. Among h1s recent
publications 1s Proceedzngs of the Second Aszan Conference on Health and
Medrcal Socwlogy, wh1eh he edited Jomtly w1th E. Isomura and others
(Tokyo: Japanese Society of Health and MediCal SoCiology, 1987).

Preface
The tdea for thts volume began takmg shape dunng the preparation for
the sesston on tradltlonal and modern medtcme, whtch was one of the
sessions orgamzed by the Research Committee on MediCal Sonology
(now Sociology of Health) of the International Sonologtcal AssoCiation
(ISA) as part of the XIth World Congress of Sociology held m New
Delht m August 1984. I was mvtted by the Chairman of the Committee,
Ray Ellmg, to orgamze that sesston. Three of the papers presented m
the sesston, namely, the paper on Hong Kong, Sonoda's paper on Japan,
and the paper on Chma, were selected for mcluston m thts volume. They
appear here, revised and enlarged, as Chapters 5, 3, and 2, respectively.
Thetr contnbutors, Rance Lee, Yuet-wah Cheung, Kymcht Sonoda, and
Lt ]mg-wet, had worked extensively on the study of mediCal systems from

XVL Preface
d1fferent perspectives and were ~peC!ally mv1ted to partiCipate m the ISA
Congress. For the other chapters, I approached Tsunetsugu Munakata
from Japan and Santhat Sermsri of Thailand, prompted by their valuable
contnbunons to the study of medical systems in their respective countnes.
Sonoda's chapter provides an overview of the lmk between traditional
and modern med1cme in Japan wh1le Munakata centres on the more
speCific area of mental health, which IS a very relevant aspect m the
high-technology and rapid pace of life m Japan m the 1980s. One of
the mam contnbunons of this book IS that 1t offers the views of socwl
sCientists from the countnes stud1ed. Of course, we paid the pnce m
terms of time. Indeed, as IS common m collaborative efforts, the bulk of
the rev1s1on work was done by correspondence. However, m the spnng
of 1988, I had the opportumty to go to BeiJing to fmalize the chapter
on Chma.
The mam a1m of this study 1s to present current documentation on the
resilience of the tradltlonal medKme system m As1an nations undergomg
rapid modermzat1on and to explore the reasons for people's persistent
combmat10n of modern and tradltlonal mediCal resources m their every-
day life. The mtended audience for this book 1s the growmg number of
soCial sCientists mterested m mediCal systems, problems of modernization
and tradltlon, and the process of modermzation and 1ts consequences
m Asia. But the book will also offer useful mformanon, as a reference
volume,
to modern mediCal practitiOners and mediCal students, particularly
those concerned w1th pubhc health and workmg m
Asia.
Fmally, I am mdebted to the kmd and valuable mspiratlon I received
from
the wntmgs of Professors Charles Leshe and Ray Ellmg and the
1deas I have been fortunate to obtam personally from both of them on
vanous occasions over the years. I wish to express my
appreciation to
the s1x contributors for their kmd co-operation m puttmg together this
volume. Without their goodwill and scholarly spmt this work could not
have been possible.
August 1988 Stella R. Quah
Smgapore

The Triumph
of Practicality
STELLA R OUAH
Until not too long ago, ethnographic descnptions of traditional healing
practices were welcomed by experts as ancient jewels of human behaviour
that had to be preserved m records before they became extinct. It was
taken for granted that such tradltlonal ways of preventing or handling
Illness would eventually disappear as people became enlightened by the
concepts and effectiveness of modern medicme.
However, as
the query on how different
communities deal with disease
contmues and more evidence Is collected, the premiss on the extmction
of traditional health practices can no longer be accepted (Leslie, 1976;
Klemman, 1984). Indeed, the study of traditional ways to treat and cure
disease has evolved from bemg the cunous subject of a few erudite scholars
to
the theme at the forefront of health care analysis by a
wide range of

2 Stella R Quah
dtsctplines. Cost-beneftt analysts, geographtcal, soctologtcal, and anthro-
pologtcal studtes suggest that tradltlonal heahng practices have survtved
the competltton of modern medtcme.
Studtes documenting the survtval of traditional health practtces sub-
stannate the argument advanced by Gusfield (1973). He tdenttfted a set
of stx fallaoes on the study of traditton and modermty, four of whtch
are fully corrected by the evtdence from the dual utihzatton of tradltlonal
and modern health servtces. These four fallactes are: "old tradtttons are
dtsplaced by
new
changes"; "tradltlonal and modern forms are always m
confhct"; "tradltlon and modernity are mutually exclusive systems"; and
"moderntzatton processes weaken tradltlons" (Gusfteld, 1973: 335-39).
Thts book addresses the dual uttlizatton of tradtttonal and modern
medtcal systems as tt takes place m soctettes undergomg raptd modermza-
tton, and seeks to document the premtss that tradtttonal practtces are
not merely "survtvmg" but, rather, they are "established" tradmonal ways
of healmg acttvely mteractmg wtth modern practices m health-related
behaviour. By analysmg the sttuatton of ftve Astan nations at vanous
stages of development and wtth dtverse cultural settings, we will be able
to compare the pervastveness of the dual use of systems of health care,
and the accommodations that have taken place m recent years on the
part of tradltlonal and modern medtcal systems to coextst and to meet
the health needs of consumers m these countnes.
Thts chapter dtscusses three aspects of relevance to the comparative
analysts of the ftve countnes mcluded m thts study. The ftrst aspect deals
with the defmmon of concepts and explams the approaches used in thts
study. The second aspect concerns the revtew of the mam theoretical
pronouncements m the social sctence literature explammg the "survival"
of tradltlonal medicine and the correspondmg data on dual health care
utthzatton.
The thtrd aspect covers the main
questions gutdmg this study
and the reasons for the selectton of the ftve countnes.
Concepts and Approaches
Soctal scientists studymg the survtval and development of beliefs, atti-
tudes, and behaviOur mvolving health and illness, have used a vanety
of terms to refer to the same phenomena thus, unwtttmgly, creatmg
confuston and hmtting the usefulness of comparative research. It appears

The Trrumph of Prawcalrt\ 3
that Klemman (1984: 140) was echomg the concern of many researchers
when he advised that "when we generaltze . we need to be preo~e
at what level of abstraction, w1th what quahflcat10ns, for what range
of practices and practit!Oners our generaltzations hold". Wh1le such deflm-
tional clarity is undoubtedly necessary, 1t 1s not sufficient m comparative
research. To facilttate and 1mprove our efforts at cross-cultural research,
we
must
"delmeate meamngful umt~ of companson" as Yoder (1982: 15)
suggested.
For
these
rea~ons, the efforts by Press (1980) at standardmng our ter-
mmology are rather timely. In th1s discussion, I shall adopt h1s defmltlon
of the followmg relevant concepts: a medrcal system w1ll be understood
as "a patterned, mterrelated body of values and deltberate practices
governed by a smgle parad1gm of the meamng, 1dentiflcat10n, prevention
and treatment of siCkness" where the term srckness "embraces both Ill-
ness and/or d1sease concepts"; the presence of more than one med1eal
system m the same soc1ety constitute a plural medrcal confrguratwn; a
folk medrcal system 1s that "based upon parad1gms wh1eh d1ffer from those
of a dommant med1cal system of the same community or sooety"; and
popular medrcme refers to "those beltefs and practices wh1eh, though
compatible w1th the underlymg parad1gm of a med1eal system, are maten-
ally or behav10rally d1vergent from offioal med1cal practice" (Press, 1980:
47-48).
Cons1denng that the thrust of th1s study 1s the analysis of the coexist-
ence of tradition and modermty in health care unltzation, two mmor
adjustments m terminology are necessary for the sake of consistency and
s1mpltficat1on. In th1s book, we shall label modern or Western med1eal
system the system that Press calls "Western b1omed1cme" (1980: 50); and
we w1ll equate tradrtwnal med1eal system with Press' "folk" med1eal system.
Concernmg the approaches used m th1s collaborative effort, we have
striven to av01d a methodologiCal straight jacket by exploring vanous
perspectives for the analysis of available mformation. The d1vers1ty in
authorship 1s reflected m the vanety of approaches taken to deal with our
subject matter. Pnmary data sources such as surveys and case interviews
have
been used, as well as secondary data such as
population statistiCs,
off1oal documents, and findmgs from other stud1es. The approaches
followed m the data analys1s proper range from statlstlcal computations
to content analysis, to h1stoncal and ethnographic descnptlons.

4 Stella R Quah
Theoretrcal and Emprncal Trends
Two analytical dimensions are involved in this study. The first dimension
concerns the concepts of tradltlon and modernity. The second dimension
is a mamfestation of the first m the realm of health-related behaviour,
namely, the dual unhzation of services from traditional and modern
medical systems. Much has been sa1d about both dimensions separately
and a review of the most Important of those Ideas in the soCiological
literature will
provide
the conceptual background to the premisses of
this study.
One of the best-known perspectives on the process of modermzation
IS provided by Eisenstadt (1973). He subscnbes to the widely accepted
differences m basic prmciples of allocation whereby tradltlonal societies
emphasize partJculansnc, diffuse, and ascnptive pnnCJples and modern so-
Cieties follow universal, differentiated, and achievement-oriented prmciples.
But,
in h1s
view, three dichotomies Illustrate what constitutes modermty
in contrast to tradltlon, namely: hberty versus authonty; change versus
stability and contmwty, and "~oCJal rationality" or "tcchmcal effiCiency"
versus cultural onentat1ons "or values such as tradltlon, religious, mystical
expenence" (1973: 4-5). These pnnC!ples emphasize a clear-cut separation
between traditiOn and modermty and seem to fit one of the fallaCJes
Identified by Gusfield (1973: 337), that Is, "tradlt!on and modernity are
mutually exclusive systems". Nevertheless, Eisenstadt proceeds to discuss
the Impact of modermzation on what he terms "the Impenal Aswn
societies" characterized by "pluralistic elements" and a "weak sociopolltlcal
order" and, m the course of h1s discussiOn, he brings up a pomt highly
relevant to this study:
the challenge of modernity was perceived and re;,ponded to by these
civilizations m ways that were often m harmony or contmwty with
codes prevalent m these soCieties and with patterns of social and cultural
change that had developed m the tradltlonal histoncal framework of
these Civilization;, (Eisenstadt, 1973· 259-60)
Wh1le h1s reference to 1mpenahsm and a weak socio-political order Is
no longer accurate to descnbe Asian nations m the 1980s, the perceived
harmony and contmu1ty to wh1ch Eisenstadt refers Is ~till current and
applicable. In fact, the pnnC!pal underlymg assumption m this study
Is that people m Third World nations do not see any conflict m usmg

The Trtumph of Practtcaltty 5
both tradmonal and modern health servtces: they perceive the modern
servtces as a complementary part of their traditional healing practices.
Scholars mvolved m the study of modermzation of traditional societies
refer to this phenomenon as the process of "d1ffus10n and acculturation"
where "old and new elements are recombmed m ways that d1d not previ-
ously exist m either sooety" (Nash, 1984: 85). It IS common to find these
concepts applied to the analysis of polltlcal and economic modernization
of traditional societies (cf. Darlmg, 1979). Although the phenomena of
diffusion and acculturation may indeed be mltlated m the economic
and polittcal arenas, they tend to 'spill over' to other aspects of people's
lives, mcludmg health-related activltles. Hence, these concepts help us to
understand the dual utilization of modern and tradltlonal health services
m
countnes with a plural medtcal
configuration.
Movmg from the general conceptual aspects of tradlt!on and modernity
to speofic studies on health-related behaviOur and attitudes, one fmds
that most studies of medical systems have paid greater attention to the
provmon of health servtces than to the utrlrzatwn of such servtces. There
IS a great deal of mterest among scholars m the arrangements, deCisiOns,
and coalltlons made at the national level for the provision of medtcal
care
to the population.
Some of these researchers suggest the application
of systems theory as the most comprehensive approach for that type
of study (cf. Krause, 1977; Elling, 1980). Others prefer to focus on the
dimensiOns of power and confltct among the healmg professions, to ex-
plam the preponderance of the modern medtcal system and the respective
subordmanon of the traditional medical system (Zeller, 1979; Asuni, 1979;
Ulin,'1979; Lee, 1982; Neumann, 1982; Taylor, 1984; Bibeau, 1979, 1985;
Leslie, 1985; Barbie, 1986; Akerele; 1987). Yet another angle of analysis
IS the economic perspective which deals with the costs and benefits of
traditional versus modern systems of medicme within a nation state (see,
for example,
Dunlop, 1979; K1khela, B1beau, and Corin, 1979).
There are
comparatively fewer studies on the users of medical care
and on the phenomenon of dual utilization of health services offered by
traditional and modern medtcal systems. Interestmgly, the latter studies
have a
common thread: they agree on a mam explanatory argument for
dual
utilization whtch I would label as pragmatrc acculturatwn, a phenom-
enon found m nations with diverse health care resources and a plural
medtcal configuration.

6 Stella R Quah
The concept "acculturation'' normally refers to an individual's or a
group's
"adoption of aspects of a culture that IS not their native one"
(Hoult, 1974: 4). This "culture borrowmg" Is not just the "movement
of thmgs among ~octetles" as some ethnographers emphasize; It also
encompasses patterns of behaviour and attitudes. Moreover, some mam-
festatlons of this culture borrowmg may be termed pragmatiC acculturation
when the borrowmg Is motivated by the desire to satisfy spectf!C needs.
As Press (1980: 47) puts It succmctly: "Human mmds compartmentalize
cultures mto a multitude of contextual and mdividual domams for flllmg
a multitude of needs." Such Is the case when people combme health
resources from different medical systems.
The prevalence of pragmatic acculturation can be better appreciated
when one considers that the daily lives of people m Third World coun-
tnes are immersed m a context of cultural diversity where tradition
and modernity are closely mtertwmed. Indeed, food choices range from
ancient staples to fast-food restaurants; entertamment involves traditional
dances, Western movies, mternational sports, and the ommpresent mass
media; dressmg
codes cover an interestmg and colourful range of
pos-
sibilities
from traditional religious attire to simple jeans and Tshirts for
family
outmgs; codes of conduct and language may vary too accordmg
to the occasion, from mformal slang m one's group dialect at home or
at the market-place, to the formal use of major language for business or
offiCial purposes.
Withm this context, It IS not surpnsing that m matters mvolvmg
health and Illness the same pattern of diversity apphes. People perceive
traditional and modern medical resources as part of their natural mosaic
of choiCes, selectmg whatever alternatives they perceive as appropnate and
useful to fulfil a particular health need. The outcome of such perception
IS the person's pragmatic and conflict-free move between traditional and
modern health services. If ever there 1s a sense of conflict, It is usually
mtroduced by modern mediCal system practitioners who routmely try
to discourage patients from combmmg resources from different medical
systems m general
but, especially, from usmg the
serviCes offered by the
traditional medical system.
Numerous studies may be cited to Illustrate empmcally the pragmatiC
acculturation argument, but a few examples will suffice. Kramer and
Thomas (1982) found that among the rural population in Kenya, "the

The Tnumph of Pracucalzt)' 7
textbook dtstmctlons of 'reltg10n', 'medtcme' and 'law' are not relevant.
These .. domains . . tended to be mterconnected or blended m every-
day life" (1982: 159). The authors distmgutsh three related levels for the
study of illness beliefs and behavtour, namely, allevtatton, eradtcatlon,
and prevention. They found that people used tradtttonal medtcme at
all three levels whtle modern medtcme servtces were used at the levels
of alleviation and eradtcatlon but not at the level of prevention (1982:
168-69). The pattern of dual use reported by Kramer and Thomas could
be found m many countnes; the overall ptcture of thetr fmdmgs shows
that many people
would expenence no conflict m resortmg to all of the followmg modern
and tradmonal alternatives. buymg shop [over-the-counter] medicmes
to alleviate the pam of headaches, seekmg a mixture from a herbalist
for a persistent stomachache, v1s1tmg a nyunyz expert for the eradication
of a chrome headache, attendmg the health center for mJecttons that
may cure bronchial pneumoma and consulnng a d1vmer for determmmg
the ulnmate cause of a senes of mtsfortunes [mcludmg tllness] (Kramer
and Thomas, 1982: 170)
From hts fteld-work in a rural area of Malaysta, Heggenhougen (1980)
concluded that vtllagers referred dtfferent types of health complamts to
health care providers m the modern and traditional medtcal systems.
Rehgtous healers
or had]ts were percetved by users as experts on
affective
aspects of illnesses that medtcal doctors would be unable to treat. A
stmilar
trend was reported
m another study on the health practices of
South Astan immtgrants m Britam by Bhopal (1986). Bhopal found that
although these tmmigrants ltved withm a Western cultural milieu, their
own cultural values permeated their deCisions on what health servtces to
use for what purpose; they mamfested a strong dnve to seek the help
of traditional healers for problems they considered outside the expertise
of modern system physiCians.
A fmal Illustration of the mfluence of pragmatic acculturation upon
dual use of medtcal systems is provided by Anderson's (1987) study of
a Cantonese village m the New Terntones of Hong Kong. Anderson
observed that his Chinese mformants beheved strongly m their mdividual
nght and obhgatlon to mamtam balance and harmony m their dally
hves m order to be healthy or to recover from illness. The villagers'

8 Stella R Quah
cultural belief on the Importance of mamtammg "a harmomous balance"
m hfe and on their nght to seek it, facilitated their perception of both
modern and traditional medical services as potentially useful for that pur-
pose; they did not see their mixed use of health services as mconsistent
or conflictive.
PragmatiC
acculturation
Is, thus, an Important factor m the explana-
tion of dual use of traditional and modern health serviCes m soCieties
with more than one medical system. However, pragmatiC acculturation
Is not the only explanatory factor; It simply Identifies the existence of
a conducive cultural mtlteu (that Is, where culture borrowmg Is accepted)
for
the
mixed use of various mediCal systems. Wtthm thts mtlteu, another
explanatory factor becomes rather relevant, namely, the accessrbrlrty of
health serviCes. This more comprehensive line of explanation suggests that
while pragmatiC acculturation Is conducive to the perception of dtverse
mediCal systems as a umfied market of healmg options, the consumer's
actual accessibility to the vanous types of health serviCes may determme
hts or her fmal dec1s10n on what services to utilize.
When Is a gtven health serviCe accesstble? The accessibility of health
services, whether modern or traditional, may be seen as a contmuum
rather than a dichotomy: from a situation where any consumer can use
the serviCe without diffiCulties whenever the need arises, to a s1tuat10n
where
the service Is available to only a few members of the commumty
under restrictive condtttons. To determme how
accessible health services
are, one may refer to five major components of accessibthty, that is,
quantitative adequacy, geographical distnbution, cost (m terms of time
and money), educat10n, and perceived accesstbtlity (Quah, 1977).
The level of accesstbtlity of a gtven service, say maternal and chtld
health clmics, increases wtth the number of such cltmcs, thetr widespread
geographical
dtstribution,
and accordmg to how affordable Is the con-
sultation fee, if any, and how much time the user is expected to mvest
when gomg for a consultation. Education IS seen as a component of
accessibility because, to utilize them successfully, different health services
require different levels
of educational sophistication on the part of the
consumers. An
Illiterate patient may be unable to use the computer
screenmg services of some climes, or may fmd it difficult to explain to
the doctor the intensity of pam or a dizzy spell whtle he or she may
feel perfectly at home talking to the neighbourhood herbalist about the

The Trtumph of Prawcaltty 9
same symptoms. It 1s clear that the lower the educational sophistication
required on the part of the potential user, the more accessible the health
service is.
The ftfth component, perceived accesslb!l!ty, 1s denved from the as-
sumption that values and behefs regardmg health and illness affect the
mdividual's perception of the accessibility of health services as well as
h1s or her dec1sion to unhze such services. Perceived access1bihty may
be defmed as "the md1v1dual's mterpretatlon of h1s chances to obtam
a g1ven health care serviCe 1.e., the difficulty or easmess with which he
thinks he could enter the health care system" (Quah, 1977: 333). Indeed,
a health care serviCe may be conveniently located and even free of charge,
but potential users may perceive 1t as maccesstble tf they see cultural or
social barners such as language, social stigma, or soCial class dtstmcttons
1mpedmg thetr use of that servtce.
In
addition to cultural beliefs and access!btlity, there 1s a th1rd factor
that, m my vtew, Improves considerably the
probability that a person uses
a gtven
health service. That factor
ts the person's subjective perception
of the beneftts of usmg the servtce. One often observes people wtllmg
to overcome great obstacles to get to a serv1ee that they see as the most
effective solution to their health problem. A factory worker's faith m the
free cl1mc's doctor may be weak compared w1th his fatth m hts home
village's healer; the worker may be compelled to travel a long distance
at great cost in order to get the healing serviCes of someone whose level
of expertise he trusts. The opposite movement ts observed among farmers
who happened to beheve that the modern medical system in the c1ty
offers the most effective solution to thetr tllness.
The combmed argument of pragmatiC acculturation, access!b!hty, and
perceived benefits of use, appears to be a more comprehensive explana-
tion of the dual utihzanon of med1eal systems than any of the three
factors alone. The extstmg body of research findmgs on health serviCes
utihzanon offers empirical support to thts argument. A few examples
wtll illustrate th1s.
In his study of the Bono community m Central Ghana, Warren (1979)
reported that people perceived diseases as
"naturally caused" and saw the
modern med1cal services as an extension of the1r own traditional system;
the1r use
of both types of health serviCes was
facilitated by the appropriate
geographical
distnbution of traditional healers and government clinics.

10 Stella R Quah
In Buganda the modern mediCal system was mtroduced by the Bntlsh
coloma! government and accepted by the local population as comple-
mentary to traditional health serviCes. However, modern health services
d1d not reach large sectors of the population; people had to travel great
d1stances
to get to a modern clime. In contrast
"traditional med1eme was
always accessible"; fam1lies knew the tradinonal healers by name; and
traditional remedies "were widely sold at bus parks, markets and wherever
people congregated" (Zeller, 1979: 252).
Descnbing the situation of the Yoruba community m N1gena, Asum
(1979) mdicated that their behefs were flex1ble enough to see harmony
rather than conflict between tradltlonal and modern med1cal systems.
Yet, Asum's findmgs showed that people perceived different benefits m
the use of tradttJOnal as compared w1th modern health services. The
average person beheved that
while modern medtcme can procure a cure, tt does not deal w1th
the bas1c cause of h1s 1llnes;, which may be a curse, the vengeance of
a god, the evil machmations of another person, etc The objective of
the traditional healmg practice m th1s situation IS to counteract the
baste cause, thereby making modern medicine effective and lastmg m
Its curative effect [thus] the traditional system complements the modern
system. (Asum, 1979. 180)
At the same time, the Yoruba mdtvlduals hvmg m urban centres had
better access to modern health services than those m rural areas: the
reverse was true concernmg tradltlonal healers. Asum observed that dual
utlhzatton was common: fam!l1es would bnng tradltlonal remedies to
thetr stck relattve at the hospttal; and they would move the sJCk person
from a medJCa! doctor's chmc to a healer's home seekmg the most benefit
from all avatlable spheres of mediCal expertise, even 1f that meant an
arduous tnp to consult a well-known and respected healer.
Yet another example of the combmed Impact of pragmatic accultura-
tion, acces;,1b1hty, and percetved bencftts ts prov1ded by Ademuwagun
(1979). In h1s study of the lgbo-Ora he reports that people perceived the
tradmonal and modern systems "as mev1table partners m the tmprovement
of thetr health condtnons, workmg complementanly rather than contra-
dlctonly . . They commute freely between the two [systems] m their
efforts to solve their health problems" (1979: 159). On the other hand,

The Trtumph of Practtcaltt)' 11
Ademuwagun found that tradmonal medtcal serv1ces were used more
frequently than modern serv1ces, gtven the greater accessibility of the
former compared wtth the latter. The average consumer knew that healers
spoke
the same language, understood
hts or her own fears, and cared
about the same aspects of h1s or her health complamts; and tradmonal
medical services were at the reach of the consumer m terms of cost and
location. In contrast, modern health services were less accesstble: the
consumer had to 'learn' how to use them; they would be more expensive;
and 1t usually reqmred a tnp to the c1ty, whtch was not always con-
vement or posstble.
In her detailed analysts of health beliefs and health behaviour m
Colombta, Pmeda (1985) reports fmdmgs along the same lmes: people were
mclmed to select health servtces from the traditional and the modern
systems accordmg to what they thought were the areas of expertise of
each system. Yet, the accessibility of modern medtcal faCilities was much
lower than that of tradltlonal servtces; cost is the mam barrier among the
urban poor; and cost and dtstance are the key obstacles rural populations
have to face to reach modern health services.
The studtes by Btbeau (1985) on the Chmese and by Taylor (1984) on
Bntam and the Umted States present data that provide further support
to the combmed concepts of pragmatiC acculturation, accesstbtlity, and
percetved benefits. In both studtes, the authors report dual utilization
of tradmonal and modern medtcal services whenever the consumers'
cultural md1eu was flextble enough to permit the coexistence of both
systems and when consumers perceived the ex1stmg servtces as effective
and access1ble.
Discussmg
the well-documented persistence of traditional
medtcal
systems m African countnes, Fabrega nghtly tdennftes two key ques-
tions for further study: "How and speCially why consumers use facets
of dtfferent systems of medtcme" (1982: 248). As mdtcated earlier, these
questions reflect the mam focus of the present study. I suggest that the
explanatory argument mvolvmg pragmatic acculturation, accessibility, and
percetved beneftts bnngs us closer to answer the why question. Ethno-
graphtc descnpnons of each commumty wdl contmue to provtde us with
culture-speCific answers to the how question.
There 1s one more relevant pomt that emerges from the scanmng of
research fmdmgs m the literature, namely, that there are two levels of

12 Stella R Quah
reality within a nation-state as far as medical systems are concerned. One
IS the official level, representing the v1ews and policies of the dominant
mediCal system, whereby boundanes are clearly demarcated between
'legitimate' and 'illegitimate' providers of health care services. Such bound-
anes imply an array of real and imagined confliCts between traditional
and the modern mediCal systems that some Interest groups promote to
prevent or delay any official attempt at mtegration.
The other level of reality 1s that of the population at large, that is, con-
sumers, as well as providers of traditional medical services. At this level,
as descnbed earlier, the average person perceives all available medical
services,
modern and
traditional, as potentially useful and chooses across
alternatives
motivated by a pragmatiC need of fmdmg the best solution
to his or her health problems, w1thm the wide array of possJbJlttJes and gmded by his or her belief of how effective and accessible the services
are.
The providers of
traditional healing serviCes may be seen as part
of th1s second level of reality because there are mdications that they
share the same pragmatiC perspective with the general publiC, that 1s, the
belief that one should use whatever means available to overcome 1llness,
whether modern or traditional, and that these two medical systems offer
solutions for different types
of illness.
In most Third World countries, these two levels of
reality are par-
allel: they coexist but do not meet. It appears that the modern mediCal
establishment ignores the second level of reality for vanous reasons, not
least of whiCh are: the lack of scientific testing of traditional medJCme
claims
and, correspondingly, the mediCal doctors' negative views on the
effectiveness and safety of the services offered by the traditional healers;
and the efforts of modern medicme to preserve its dommance.
Basrc Ouest1ons
The precedent rev1ew of fmdmgs on health services utilization m countnes
w1th traditional and modern med1cal systems has established that dual
use of health services 1s prevalent; and that researchers are still unclear
as to why people use both traditional and modern serviCes. Available
fmdings also indicate that a formal mtegration with the traditional system
would be complex
and 1s resisted by the modern mediCal system (see, for
example, Akerele,
1987; Barbee, 1986; Bibeau, 1985; Twumas1, 1982; Lee,

The Tnumph of Practrcalrty 13
1982; Koss, 1980; Ademuwagun, 1979; Quah, 1977); and that tradltlonal
healers have often made attempts to adapt to or emulate modern health
serv1ces (for example, Quah, 1977; Ulm, 1979; Zeller, 1979; Lee, 1982).
Departmg from these fmdmgs, this book addresses three important
questions snll unanswered. The first question focuses on the conceptual
concern with understandmg people's cho1ces across cultures and the need
to d1scover general trends, that 1s, "What are the promment patterns (1f
any) of dual unhzanon of health serviCes?" The second question probes
the 1mpact of changmg social condltlons and consumer preferences 10
Th1rd World countries, that 1s, "Does dual unhzat1on of mediCal serviCes
d!mm!sh w1th modermzat10n?" The third research question refers to
the coexistence of the two levels of reahty and deals w1th health pohcy
formulation, namely, "What 1s the current role of the government with
respect to the controversial collaboration or mtegratlon of modern and
tradltlonal med1cal systems?"
The flrSt question will be taken up 10 Chapter 8 where the s1milant1es
and differences among the five nations (People's Republic of China, Hong
Kong, Japan, Smgapore, and Thailand) will be compared and analysed
to probe further the comb10ed explanatory argument of pragmatiC accul-
turation, access1b1hty, and perce1ved benefits of us10g health serviCes.
The other two questions gmde the d1scuss1on 10 Chapters 2 to 7 where
the situation of the five 10d!v1dual nations Is discussed and w1ll also serve
as a frame of reference for the summary of the ma10 study fmdmgs 10
Chapter 8.
Why These Frve Natrons7
The pnnClpal cnterion for the selection of the five nations 10 th1s study
was "umty m d1vers1ty". G1ven the nature of the subject under 10vesnga-
tl0n, the countries mcluded had to be from the Th1rd World and had
to meet the basK requirement of a plural mediCal configuration. At the
same time, m order to probe the basK quest10ns gu1ding th1s study, it was
necessary
to select countnes at different stages of modermzatlon or socio-
economiC
development and w1th d1fferent levels of cultural homogeneity.
Furthermore, for the sake of expediency, it was necessary to work with
a manageable number of countries. The five nations selected meet all
these requirements. Wh1le all
the
five are As1an countries w1th tradltlonal

14 Stella R Quah
and modern med1cal systems, they are different m relevant respects as
Illustrated m Table
1.1.
In terms of sooo-econom1c development and modermzatton, roughly
estimated by the md1cators m Table 1.1, the
ftve countnes occupy d1fferent
pomts m a contmuum. At one extreme 1s Japan, a h1ghly mdustnaltzed
nat1on and one of the world's economiC g1ants. Japan 1s followed by
Smgapore
and Hong Kong, two nations undergomg rap1d mdustnaltzatlon
with h1gh gross
national product (GNP) per cap1ta, rather low mfant mor-
taltty rates, and h1gh ltfe expectancy. Next IS Tha1land, With Its growmg
GNP but a lower !tfe expectancy, a h1gher mfant morta!tty rate, and w1th
the burden of a large hmterland. Further down the contmuum IS Chma,
w1th the lowest GNP per capita, the highest mfant mortahty rate, hfe
TABLE 1.1
Comparison of Indicators of Development of Five Selected Countries
Population Ltfe GNP per
Estimate Infant Expectancy Captta
Mtd-1986 Mortahty at Bmh Percentage 1983
Selected (mt!hom) Rate (years) Urban (US$)
Countnes (1) (2) (3) (4) (5)
---------
Chma 1,050.0 so 0 64 32 300
Hong Kong 5.7 9.2 75 92 6,070
Japan 121.5 6.2 77 76 10,100
Smgapore 2.6 9.4 71 100 6,660
Thatland 52.8 48 0 63 17 820
Source Population Reference Bureau (1986 ). Ito, dcfmltlom of the above mdt-
catoro arc as follows.
(1) Estimate:, based on a recent census, or on U.N. or offiCial country pubhcanom.
(2) The annual number of deaths of cht!dren under age one year per 1,000
btrth,.
(3) The average number of years a new-born mfant can expect to hve under
current mortahty levels.
(4) Percentage of the total population hvmg m areas termed urban by that
country.
(5) The gross national product (GNP) per cap1ta ftgures are fmal ftgures from
the World Bank.

The Tnumph of Pracucallty 15
expectancy figures close to those of Thatland, and the second lowest level
of urbamzatton after Thatland.
The ftve countnes also dtffer concermng cultural homogenetty. Three
of them, Chma, Japan, and Hong Kong, are nearly homogeneous as the
large ma]onty of thetr populations belong to one ethmc group. Thatland
is moderately heterogeneous: "85 per cent [of tts population] speak a
dtalect
of That and share other features of culture mcludmg Theravada Buddhtsm" (Bunge, 1981: 61). Smgapore ts a mulnethmc nation: tts popu-
lation ts composed of three mam ethmc groups: Chmese (76.4 per cent);
Malays (14.9
per cent), and Indtans (6.4 per cent); the remammg 2.3 per
cent involves vanous small ethmc minonttes (Mmtstry of
Commumca-
ttons and InformatiOn, 1986: 7).
The beneftts of comparing these culturally and economically dtverse
nations wtll become more evtdent as the dtscusston progresses. But what
ts clear at this pomt ts the Importance of testmg the conceptual premtsses
on dual utilization of medtcal systems under dtfferent socto-structural con-
dttions. As the preceding dtscusston mdtcates, the baste assumptton to
be tested ts people's mclmatton to tgnore the offictal boundaries separatmg
medtcal systems
and to make use of whatever resources they consider
useful to sattsfy thetr health needs; m other words, the tnumph of
prac-
ttcaltty over theorettcal and formal distmctions.
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of
Traditional Health Care Systems and Methods wtth Modern
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Asunt,
T.
"Modern Medtcme and Traditional MedKme". In Afrzcan Therapeutzc

16 Stella R Quah
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1981.
Darhng, F.C. The We.1termzatwn of A sra A Comparatrve Analym Cambndge,
Mm,s.· Schenkman Pubh,hmg Co., 1979.
Dunlop, D.W. "Alternative" to 'Modern' Health Dehvery Systems m Afnca.
Pubhc Pohcy Issues of Tradmonal Health Sy,tem,". In Afncan TherajJeutrc
S:vstem.1, edited by Z A Ademuwagun, J A A Ayoade, I.E. Harnsson, and
DM. Warren, pp. 191-96. Walthan, MA. Afncan Studies A"ooatton, 1979
Eisemtadt, S N. Tradrtwn, Change and Modernrt\', New York. John Wdey &
Sons, 1973.
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Care.
New Brunswick, N
].· Tramactlon Books, 1980.
Fabrega, H "A Commentary on Afncan Sy,tem" of Medicme" In Afncan
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Boob, 1lJ73

The Tnumph of Pracucalzty 17
Heggenhougen, H.K. 'The Unhzanon of Tradltlonal Medtcme - A Malaystan
Example". Soczal Sczence & Medzczne 14B (1980). 39-44.
Hoult,
T.F. Dzctzonary of Modern Soczology. Totowa, N.].:
Lzttlefteld, Adams,
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Health m Zatre". In Afncan Therapeutzc Systems, edtted by Z.A. Ademuwa-
gun,
J A A Ayoade, I.E Harnsson, and
OM Warren, pp. 217-24. Walthan,
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the Tradtttonal Healmg System to the
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Soczal Sczence & Medzczne 14B (1980): 267-78.
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and A Thomas.
"The Modes of Mamtammg Health m Ukambam,
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R.P.L.
"Comparative Studzes of Health Care Systems". Soczal Sczence &
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Nash, M
Unfznz.1hed Agenda The D:vnamzcs of Modernrzatron m Detdopmg
Natwm. Boulder, Col We"tvtew Press, 1984
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18 Stella R Quah
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"Problems m the Oefmttlon and Classtftcatlon of Medtcal Systems".
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"Alternative Medtcme and the Medtcal Encounter m Bntam and
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Twumast,
P.A.
"Improvement of Health Care m Ghana. Present Perspectives".
In Afrzcan Health and Healzng Systems Proceedzngs of a Symposzum, edtted
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I
E. Harnsson, and D.M Warren, pp. 243-47 Walthan, MA: Afncan Studtes
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Harns:,on, and OM Warren, pp. 251-56. Walthan,
MA: Afncan Studies Assoctatlon, 1979.

2
Marriage of Convenience:
Traditional and
Modern
Medicine in the People's Republic of China
STELLA R OUAH and Ll JING-WEI
Much has been wntten about the struggles and successes of the People's
Repubhc of Chma (PRC) m prov1ding adequate health care to 1ts over
one bilhon ottzens - a population of 1,015,410,000 m 1982 -scattered
over approximately 9.6 m1lhon sq. km.
of territory. Th1s chapter attempts
to prov1de an updated look at the s1tuat1on from a pohcy
perspective,
namely, the outcome of about thtrty-e1ght years of an off1nal merger
pohcy,
or marnage of convemence, between the
traditional and modern
medtcal systems.
The PRC 1s the only country that has Implemented a pohcy of integra-
tion of tradmonal and modern systems of medtcme, following a top-down
approach consistently. In contrast, most developed and developmg nations
present a situation where the offtc1al government pohcy 1s to promote

20 Stella R Quah and Lz ]mg-wez
and support the modern health care system m preference to (and often
agamst) tradltlonal alternatives of health care while both traditional
and modern medical systems are regularly combined by people m their
everyday life. Accordmgly, the discussion of Chma's case m this chapter
IS divided into four parts. The first part Is a bnef exammation of the
h1stoncal background supportmg the offiCial mtegration of tradmonal
Chmese med1cme and modern (also referred to as "Western") med1cme.
The second section presents the most signifiCant features of the merger
policy. The third section highlights the main current features of the
combmed provision and utilization of traditional and modern medical
services
in Chma. The most
salient fmdmgs are summanzed m the con-
cludmg section.
Hlstoncal Prelude to the Merger
Perhaps the best-documented aspect of civilization m Asia IS the develop-
ment of traditional Chmese mediCme. Nearly 10,000 books or manuscnpts
on Chmese medical theory and therapeutic techmques have been pre-
served, the earliest of which date back to around 221 BC (Lm and Zhu,
1984: 6). This body of mediCal knowledge represents the accumulation
of vanous tradltlons mcludmg the Zhong Y1 which refers to tradltlonal
Chmese med1cme m the broadest sense; Tibetan (~); Mongolian ('t);
Uyghur (ilft-'8-it); Zhuang (;!±); Korean (.¥Jl SU.f); and Da1 (1~) tradltlons,
all of whiCh cover theory and therapeutics.
H1stoncally, the government has played a very Important role m the
development of traditional Chmese mediCme. Sh1 Huang (~-!Iii j_), the
first Emperor of the Qmg dynasty (221-206 BC) ordered the burnmg of
all books and the burymg of mtellectuals, but he spared medical books
from that destruction. The rulers of successive dynasties promoted the
compilation and preservation of mediCal literature from all corners of their
empire as a symbol of cultural achievement. Emperor Gaozong (~ ~)
of the Tang dynasty (AD 618-907) accepted the suggestion of Chinese
physiCians and pharmacologists to set up a team of some twenty physi-
cians with the task of rev1ewmg the ex1stmg medical literature on herbs
and compile drawmgs and speomens of herbs with the help of local
authonties throughout the country. The outcome of their work was the
Xm Xzu Ben Cao (#Jj-1f;f-.$) [Revised herbology], which was wntten
and widely distnbuted m AD 659.

Marnage of Convemence m Chma 21
Dunng the Song dynasty (960-1280) the government set up the Bureau
for
the
Recttflcanon of MediCal Books (~tiE -1-"t hi) to proof-read, correct,
and update the medtcal ltterature wntten before the Tang dynasty and
to publish thetr work m pnnt. At the same ttme, the Offtcial Bureau
for
the Regulation of Drugs was
establtshed to momtor the quahty and
effectiveness of medtcmes sold to the pubhc. The work of this bureau
was cructal m raising the social standmg of physictans and pharmaco-
logists m addttton to safeguardmg the health of the population.
The Importance of government poltcy was evident not only m tts
posttive effects but also m tts negative consequences for the develop-
ment of tradlt!onal Chinese med1eme. For example, in 1822, the lmpenal
medical authonty declared that acupuncture and moxtbustion were not
suttable to the emperor. The Department of Acupuncture and Moxtbus-
tlon at the lmpenal Hospttal was closed permanently by tmperial order
and the development of acupuncture suffered a senous set-back for a
long ttme after
that offioal move.
The best
Illustration of the strength of the government's mfluence
m
modern ttmes
ts the long-standmg controversy on how to deal wtth
two dtfferent mediCal systems, namely, tradinonal Chmese medicine and
modern (or Western) medteme. A htstoncal analysis of the begmnmgs
of tradttional Chinese medtcme mdtcate that some "medtcal ltterature"
from the West and, particularly from India, "reached China as early as
the fifth century" (Cai, 1988: 1) and that there was a strong Buddhist
influence from "anctent lndta" m tradtttonal mediCal practices in Chma
m the stxth and seventh centuries. Arabtan medicine reached China
through Arab merchants m the thirteenth and fourteenth centunes
(Cat, 1988: 2). But Western medtcme was more ftrmly introduced m
Chma by missiOnaries such as Matteo RKct, N1eollo Longobardi, Julto
Aleni, and Johann Adam Schall von Bell, all of whom reached Chma
between 1597 and 1629, and "translated western books on astrology, water
conservation
and medtcme into
Chinese" (Chen Hatfeng, 1984a: 16).
However, from the begmnmg of the seventeenth century to the end
of the nmeteenth century, Western mediCine was not more than an
Intellectual cunostty m Chma, and the contradictions between the two
medical systems
did not go beyond academic discussion. There were very
few Chinese doctors practising modern medicine at that ttme. Avatlable
figures
indiCate that there were "ISO mtsstonary physiCians" in 1887, "most
of them Amencans, mcludmg 27 female physicians" (Cat, 1988: 3).

22 Stella R Quah and Lz ]zng-wez
The onset of the twentteth century wttnessed an mterestmg change.
Dunng the ftrst decade, before the 1911 RevolutiOn, the number of
doctors trained in Western medtcme mcreased and the achievements of
Western medtcal treatment recetved pubhc attentton. Chmese doctors
were gtven social recognition and placed m dominant posltlons m the
official medtcal servtces whtch current Chmese histonans say catered only
"to the tmpenal rulers and mvadmg tmpenahst armtes and dtplomattc
offtcials" (Chen Haifeng, 1984a: 16).
Western medtcme recetved the dectstve tmpetus from the Nationahst
government after the 1911 Revolutton. The Chmese Medical Assonatton
was formed m 1915 and the general offtctal attitude was clearly leanmg
towards the adoptton of Western medtcme. The Nattonahst government
estabhshed the ftrst Pubhc Health Affatrs Office m Bet]mg m 1925 and
the Mmtstry of Public Health m 1928 as part of the pubhc health services
mfrastructure patterned after the Umted States model (Chen Hatfeng,
1984a: 18). By 1932 there were 5,390 modern medtcme doctors m Chma,
87 per cent of them Chinese and 13 per cent foretgners; 1,422 nurses,
50 per cent of them Chmese; and 2,941 medtcal students (Chen Hatfeng,
1984a: 22).
An open clash between the supporters of each medical system was
provoked by the Central Health Commtsston's btl! to abohsh tradltlonal
Chmese medtcme. The government's posltlon m thts btl! was actually
based on the work of Yu Yunxtu (~'*'.LJJ), an erudtte medtcal scholar
born m 1879. Yu studted Western medtcme m Osaka and, upon hts return
to Chma learned tradltlonal Chmese medtcme and pharmacology. In
h1s book entttled Gu Oat ]z Bzng Mzng Hou Su Yz (-;1;1\*-¥i-t1
1~JJ\L,J\).
[Treatt~e on anuent medtcal termmology and mamfestattons of dtseases]
he cnttuzed the "unsctenttftc" aspects of tradmonal Chmese medtcme.
Hts
book had a constderable tmpact upon academtc and
offtual ctrcles.
In 1929 Yu put forward a proposal to the Central Health Commtss10n
advocatmg a "medtcal revolutton" whereby tradltlonal Chmese physt-
ctans should be removed for the sake of the pubhc's health and welfare;
the presence of tradltlonal medtcme, accordmg to Yu, prevented people
from
changmg thetr attttudes and acceptmg more developed health care
methods. He suggested the banmng of tradltlonal medtcme schools and
advertisements of tradltlonal medtcme m the mass
medta; prohtbttmg
tradltlonal Chmese phystctans from tssumg death certtftcates when the

Marnage of Convenzence zn Chzna 23
cause of death was a commumcable d1sease; g1vmg a spec1al ftfteen-year
ltcence to practise to traditional Chmese phys1c1ans over f1fty years of
age; and requ1rmg traditional Chmese phystc1ans below the age of ftfty
to undergo trammg m modern medtcme w1thm a penod of ftve years
10 order to obtain a ltcence to practise as modern doctors. The a1m of
these steps was to ehmmate the practice of tradltlonal Chmese medtcme
10 the course of fifty years. Yu's proposal was accepted by the Nationahst
government and became Its mam polttlcal document and gUldelme for
the ehmmatlon of tradltlonal Chmese medtcme.
Th1s offic1al stand prompted an mtense poltt1cal struggle on the part
of Chmese phys1c1ans who all along had contmued the1r struggle to
prevent the Nationahst government from banning traditional Chmese
medtcine altogether. Tradltlonal Chinese physicians opposed the proposal
by bringing
together the1r hitherto scattered organizations mto a
"national
congress" held m Shanghai on 17 March 1929. A movement involvmg
132 groups of tradltlonal Chmese phystclans from fifteen provmces was
transformed mto the organization Umted Petttion Group to Bel]tng for
the purpose of ftghtmg for the cancellation of the Central Health Com-
mlsston's btl!. The Group's motto was that the promotion of traditional
Chinese medtcme was an effective way to counteract foreign econom1c
and cultural mvas1ons. The Group obtained considerable support at
home and from overseas Chmese.
In response, the Natlonahst government made some concessions dunng
the followmg years, by setnng up committees to study tradmonal Chmese
medtcine Within the Central Hall of National Medtcme, the Pubhc Health
Offtce, and the Mimstry of Education. In 1931 the Natlonahst government
set up the Central Academy of Tradltlonal Chmese Medicme m Nan]mg
With branches m vanous provmces and promulgated a set of Regulations
for Tradltlonal Chmese Medtcine. But, m sp1te of these concessions, the
Nationalist government contmued the1r support for the modern medtcal
system
as these were the only steps taken and
"no substantial changes
were made w1th regard to the pohctes d1scnmmating agamst traditional
medtcme" (Chen Hatfeng, 1984a: 23).
Before the commumst revolution, the s1tuat1on remamed bastcally
the same: the government favounng the modern med1cal system and
tradltlonal Chmese phys1c1ans strugglmg to achieve offtc1al recognition
and to av01d further legal d1scnmmat1on. The controversy contmued,

24 Stella R Quah and Lz ]mg-wez
not only m offioal and academiC circles but also among the common
people. There was a declme m the number of young students of tradi-
tional Chmese medicme, and many middle-aged Chmese physicians
moved mto other occupations; only the oldest or "last generation" of
Chmese physteians was left.
The Merger
While the NatiOnalist government was promoting the use of modern
medteme among the people, Mao Zedong's revolutionary forces were
engaged
in a different endeavour. They had to cater to the health needs
of their growmg Red Army under rather
diffteult circumstances and the
combmed use of tradmonal and modern medteme was advocated by Mao
as a matter of practicality and efficient use of available resources. The
posltlve results and experience obtained during the revolutionary civil
war m
the combmation of both types of
medteme were mvaluable and
deos1ve for the health policy later adopted by the commumst government.
Between
1928 and 1949 the Red Army
actively made use of both
Western and traditional Chinese medicine. The firSt "med1cme depot"
of the Red Army was a cargo of "25 to 30 tons of herbal medicme"
captured m May 1928 m the county of Yongxmg. In November that
year, Mao "urged hospitals to combine Chmese med1cme with western
medteme m treatmg disease" (Chen Ha1feng, 1984a: 25). Following the
Western system, pharmaceutical plants were set up to produce "glucose,
sulfamlam1de, anesthetics, vaccmes and serum" (1984a: 38); the Central
Military Revolutionary Committee set up a comprehensive network of
health orgamzations comprismg operation teams and hospitals as well as
ep1demte prevention committees m every company (1984a: 40-41); and the
treatment of the wounded included "relay stretcher teams" to minimize
the time lapsed before operation or treatment, "plastic bandages, regular
change of dressmg, and delayed sutunng" (1984a: 42).
The foundation for a combmed system of health care was thus estab-
lished before the creation of the PRC on 1 October 1949. The followmg
year,
on 7 August
1950, Chairman Mao opened the FirSt National Health
Conference with the declaration
Umte new and old medtcal personnel from all sectors of both tradi-
tional Chmese and Western medtcme to form a consohdated umted

Marnage of Convenrence m Chma
front and struggle for the development of the great people's health
serviCe. (Chen Hmfeng, 1984a: 45)
25
Four "gutd10g pnnc1ples" of national health pohcy were established
between 1950 and 1952, three of them at the F1rst Nanonal Health Con-
ference and the other by Prem1er Zhou Enla1. These pnnciples were: to
serve "the peasants, workers and sold1ers"; to give "pnonty to preventive
over curative med1c10e"; to foster "umty between practltloners of trad!-
nonal Ch10ese med1c10e and practltloners of western mediCine"; and
to make "health work a pnmary focus for mass movements" (L10 and
Zhu, 1984: 2).
Thus, the presentation of the merger as a patnotlC duty and the full
support of the pohncal leadership beh10d the implementation of the
merger ensured 1ts success. Although there are no available figures on
the use of tradltlonal Ch10ese med1c10e dunng the Nanonahst reg1me,
the anoent roots of tradltlonal Ch10ese med!Cme 10 the population
allow us to assume that the Nanonahst government's preference for mod-
ern med1one d1d not reflect people's cho1ces 10 health care and that
tradltlonal remed1es and procedures cont10ued to be used by people
10 the1r dally lives. The commumst government's d1rect1ves for merger
and collaboration were then d1rected mostly at the practitioners of both
systems of med1c10e, particularly the modern doctors who had been the
benef!oanes of the prev10us regime's poliCy of separation.
Apart from the pohtlcal ga10s of pleas10g the large majonty of the
Ch10ese population, the pragmat1c aspect of thts pohcy of merger is evi-
dent when one analyses the figure on health care pracnnoners avatlable in
1949 when the Commumst Party took over. There were that year 38,000
modern doctors, 276,000 tradltlonal Ch10ese physiCians, and 363,400
practitioners of both trad1t1onal and modern med1e10e (Chen Zhongwu,
1984: 80). That 1s, only 5.6 per cent of all med1eal personnel were dedi-
cated exclusively to modern med1c10e and the majonty (53.6 per cent)
were hkely products of the Nationalist pohcy forc10g tradinonal Chmese
physicians below fifty years of age to be retra10ed 10 Western med1cme
as 10d1cated earl1er. Even 1f the new government had wanted to rely
solely
on modern
mediCine, the number of doctors available was JUSt
too small to prov1de modern health care to a large and needy population.
In 1949 the adult mortahty rate was 25 per 1,000 of the populanon; the

26 Stella R Quah and Lz ]mg-wez
mfant morta!tty rate was 200 per 1,000; and the average !tfe expectancy
was thtrty-flve years (Lm and Zhu, 1984: 4). Undoubtedly, then, there
were strong pragmatic reasons for the commumst government's formula-
tion and dec1s1ve tmplementatton of the merger policy.
Frwts of a Marnage of Conventence
It 1s not unusual for a new polltlcal regtme, particularly a revolutionary
one, to promise sweepmg reforms and take radtcal poltcy measures. But
the polltlcal htstory of most countries 1s littered wtth unfimshed pro-
grammes and broken prombes. It 1s because of thts pattern that the PRC
'tands out as a umque case of perseverence and success m Its health
care poltcy. Over the past decades smce the communist revolution, the
policy of merger of tradltlonal and modern systems of medtcme has been
Implemented consistently despite many problems faced over the years.
The outcome m the 1980s could be satd to be successfultf the yardstiCk
1s not a direct companson wtth the htgh technology medtcme of Western
mdustnaltzed nations but, rather, an assessment of the accessibility of
pnmary health care serviCes to the population.
Indeed, one of the Important aspects of accesstbiltty to health care
serviCes 1s cost. China has stnven to provtde free medtcal services as far
as posstble. Accordmgly,
there are three mam types of medtcal schemes:
(1) the
"state-run free mediCal system" covenng ctvtl servants, teachers,
and medtcal practltloners, whether m acttve serviCe or retired, requires
only a nommal fee of 0.10 rmb yuan (about US$0.03) per vtslt and their
famtly members may get reimbursement of up to 50 per cent of the
total cost at designated cltmcs m some regtons; (2) the "enterpnse-run
free medtcare system for staff and workers" covenng all employees of
"factones or businesses run by the state, Cities or counties" as well as up
to 50 per cent of the medtcal expenditure mcurred by family members;
and (3) the "co-operative medtcare program" covering about 70 per cent
of the total population !tving in rural communes. Thts scheme has two
versions, namely, the "collective program" and the "co-operative program"
proper. The "collective program" refers to the health serviCes run collect-
Ively by the bngade or commune, whiCh can be used free of charge "by
every member of the community". The "co-operative program" on the
other hand, 1s a scheme whereby members of the commune pay "one to

Marnage of Convenrence m Chma 27
two rmb yuan annual membership fee" (about US$0.28) wh!Ch entitles
them to free mediCal care (L1u, 1985: 98-99).
The basiC md1cators of health status m the population have Improved
considerably smce
1949. For example,
m 1982 the adult mortality rate
declmed to 6.6 per 1,000 of the population; the mfant mortahty rate in
urban areas was 13 per 1,000 hve births and m rural areas 22 per 1,000;
and the average hfe expectancy had mcreased to sixty-nine years.
One of the mam reasons for these Improvements 1s the orgamzanon
of the health services nat1on-w1de both m Its admmlstrative and med-
ICal aspects. At the national level, health pohcy and the prov1s1on and
admmlstranon of health services are co-ordmated by the Mmistry of
Health and three other regional-level organs as illustrated in Figure 2.1.
The medical departments at each level set up and adm1mster hospitals
and health fac!hties m urban and rural areas mcludmg "mediCal co-
operatives and JOint cl1mcs and the supervision of 'barefoot doctors'"
(Chen Zhongwu, 1984: 81).
Rural medical services are managed through rural pubhc health bureaux
using a comprehensive "three-tier" network of health care services. As
F1gure 2.2 Illustrates, the three ners of the network mvolve counties,
townships, and bngades. Accordmg to official figures for 1981, there
were 4,118 county hospitals throughout the twenty-two provmces of the
FIGURE 2.1
Organization of National Health Services
MINISTRY OF PUBLIC HEALTH
II
PROVINCIAL AND AUTONOMOUS REGIONAL
PUBLIC HEALTH DEPARTMENTS
(Reg1onal and Mun1c1pal)
II
CITY OR PREFECTURAL PUBLIC HEALTH BUREAUX
II
COUNTY AND URBAN DISTRICT PUBLIC HEALTH BUREAUX
(Autonomous County Health Bureaux)
Source Adapted from F1gure 4.1 m Chen Zhongwu (1984: 81).

28 Stella R Quah and Lr ]mg-wer
FIGURE 2.2
Three-Tier Network of Health Services in Rural China
AUTONOMOUS COUNTY HEALTH BUREAU
[County hosp1tal, trad1t1onal Ch1nese mediCine hospital, ant1-ep1demlc
stat1on,
maternal
and child health stat1on. drug 1nspect1on station,
health cont1nuat1on school, and prevent1ve clin1cs for spec1al disease-,]
II
TOWNSHIP GOVERNMENT
(People's Commune)
[Rural or commune hosp1tal, clin1cs or health care centres
1n enterprises, schools, and government bod1es]
II
RURAL PRODUCTION BRIGADE
(Villagers' Committee)
[Bngade cl1n1cs or co-operative med1cal stat1ons]
Source Adapted from F1gure 4 13 m Chen Zhongwu (1984· 104).
country, prov1d10g 448,633 beds; 55,400 commune hospitals offenng a
total
of
775,000 beds; and 610,079 bngade cl101cs or co-operative medical
stations with 1,396,452 barefoot doctors (Chen Zhongwu, 1984: 105).
Cons1denng the 1981 total population of about 1,015 million, these figures
amount to one county hospital bed for every 2,263 persons; one com-
mune hospital bed for every 1,310 persons; and one barefoot doctor for
every 727 persons.
As these are rural health serviCes, the actual ratios may
be better 1f one excludes the urban population, wh1ch 1s approximately
32 per cent of the total
populatiOn (Population Reference Bureau, 1986).
Further details of the ImplementatiOn of the merger policy 1s provided
10 Table 2.1 by some features of the modern and traditional health care
services available 10 Ch10a today.
It IS noteworthy that although the population has more than doubled
10 the span of four decades, and the percentage of the national budget
dedicated to health Is modest, 10fant and adult mortality rates have
declmed,
and the number of health care services and personnel has
m-
creased. It appears that the strategy of makmg full use of md1genous
or traditiOnal health practitiOners and remedies to complement modern
mediCal faolmes and personnel has worked and pa1d well m Chma.

TABLE
2.1
Traditional and
Modern
Health
Services
in
China,
1949,
1981,
and
1985-86
Features 1949
1981
1985-86*
Total
population
(m!lhons)
5ooa
1,0
15b
1
,050(
Infant
mortahty
rate (per
1,000)
200d
17.5J
soc
Nanonal
health
budget
(btlhon
yuan) n
a.
32
74e
64.28e
Percentage
of
nattonal budget allocated to
health
n.a
2.94%e
2.81
%e
Number
of
general
(city) hospitals
1,
140a
6,670a
8,960h
Number
of
tradltlonal
Chmese
med1cme
hospitals
n.a. 878a 1 ,576h
Number
of
merged practtttonersf
363,400" 1,396,452" 1,413,000g
Number
of
tradltlonal
Chmese
phys1c1ansh
276,000
n.a.
341,000
Number
of
semor doctors
of
Western med1cmeh
38,000
n.a.
619,000
Number
of
Juntor doctors
of
Western med1oneh
49,000
n.a
482,000
Average
number
of
tradlt!onal
Chmese
phys1c1ans
na
77
65
m tradlt!onal
Chmese
med1cme hosp1talse
Average
number
of
modern
doctors
m
n.a
75
48
tradlt!onal
Chmese
med1cme hosp1talse
3:: IOl --<
--< s.
(JQ "' 0 ~
n 0 ;::l e: "' ;::l ;:;; ;::l r, "' 5 n ;:,-- 5 IOl N 'D

TABLE
2
1 (Contmued)
Features
1949
1981
1985-86*
-------
------
Annual
number
of
patients
seen by n.a.
2,034,608
2,410,298
tradltlonal
Chmese
phystClans m Bet]mge
Annual
number
of
patients seen by n.a.
22,654,865 27,916,218
modern
doctors m
Betjtnge
*
The
sources used for ftgures m thts
column
do
not
provtde all
the
mformatlon
for
the
same year.
The
latest
ftgures avatlable are
only
for
1985
or
1986,
thus
thts
column
covers
both
these years.
See
the
sources for
mdt-
vtdual
Item'
below.
a
Accordmg
to
ftgures
provtded by
Chen
Zhongwu
(1984:
79-88,
112-15).
h
Estimation based
on
the
1982
ftgures reported by
Chen
Hatfeng
and
Zhu
(1984.
xv).
L
As
reported by Population Reference Bureau
(1986).
d
Lm
and
Zhu
(1984:
4).
e
Ftgures from
the
Mmtstry
of
Pubhc
Health,
Chma.
I
The
term
"merged
practitioners" refers
to
health
workers
tramed
m
both
traditional
Chmese
medtcme
and
modern
medtcme.
Smce
1958
all
of
these
practltloners
workmg
part-time
"along
stde
the
peasants
m
nee
paddtes"
have
been
called
"barefoot doctors"
(Chen
Zhongwu,
1984.
112).
Today merged
practitioners
mclude
semor-level
physJCtans graduated from
modern
medtcal schools
who
have
undertaken
courses
m
tradltlonal
Chmese
medtcme
rangmg from
stx
months
to
two years
The
total
number
of
such
modern
doctors
graduated
from
1958
to
1984
was
131,305
(Mmtstry
of
Pubhc
Health,
PRC,
1985:
16)
Mmtstry
of
Pubhc
Health,
PRC
(1986·
12)
h
State Statistical
Bureau,
PRC
(1988·
741-42,
749).
n.a mdtcates
that
ftgure'
arc
not
available
\.N a (/] li s- ;:>::J 9 "' ;:>-"' ;:l l'l.. t' '-~ t: ~

Marnage of Convenrence m Chma 31
Two htgh-rankmg members of the health servtces estabhshment m charge
of health pohcy, Dr Zhu Chao, the Deputy Secretarv-General of the
Mtntstry of Pubhc Health's Commtttee of Medtcal Soences, and Dr Lm
Wet, former Asststant Chtef of the Department of Tradmonal Chmese
Medtcme, Mmtstry of Health, explam the Chmese approach:
The heart of the policy toward tradltlonal Chmese medlCme 1;, to
carry
1t forward and develop It, encourage doctors of Western
medtcme
to learn and study tradltlonal Chme;,e medtcme, apply what has heen
achieved m modern 'SCience and technology to update the theones,
and practl'ie the mtegratton of both branches of medtcme. (Lm and
Zhu, 1984: 6)
The mtegratton of the tradltlonal and modern medtcal systems has
been dynamtc, wtth emphasts on JOmt development and mutuallearnmg.
The case of barefoot doctors tllustrates the rural angle of the Implementa-
tion of the merger policy. The ongms of thts type of tradltlonal health
workers date back to the early years of the commumst regtme when the
government tssued dtrectlves for the settmg up of "health stattons" m
rural areas
and the formmg of a grass-roots health movement emphasmng
dtsease
prevention and pubhc health education. In 1958, health stations
became part of the people's communes, were called "production bngade
chmcs", and were run by peasants who doubled as "part-time medtcal
workers
wtth rudtmentary
sktlls" whom the farmer-patients called barefoot
doctors. Barefoot
doctors have become an estabhshed and tmportant part
of the rural health care servtces m the 1980s. Workmg m the
production
bngade clmtcs, etther alone or m teams of two or three, tt ts estimated
that they attend to 60~ 70 per cent of all out-patient consultations m
the country (Chen Zhongwu, 1984: 112).
Moreover, candtdates for the post of barefoot doctor are selected "by
members of thetr productton bngades" among "juntor mtddle school
graduates" who are "sound pohttcally, honest and upnght and healthy,
and mterested m medtcal work" (Chen Zhongwu, 1984: 113~14). Then
they must undergo a stx-month trammg and certification course whtch
mcludes baste pnnoples of medtcal sctences, pharmacology, and preventive
and clmtcal medtcme, mvolvmg both tradtttonal Chinese medtcme and
modern medtcme; after certtficatlon, retrammg courses must be attended
periodtcally (1984: 114~15).

32 Stella R Quah and Lz ]mg-wez
A large body of ltterature has been produced by the health authontles
to assist barefoot doctors m the1r pract1ce. Among the most recent pub-
liCations are Rural Medzcal Sczences zn Chzna and Teachzng Materzals for
Barefoot Doctors zn Chzna, as mentioned by Chen Zhongwu (1984: 115).
But perhaps the best-known book m the West 1s A Barefoot Doctor's
Manual
(Fogarty InternatiOnal Center, 1977). This manual 1s a concrete
example of the combmatlon of modern and tradltlonal mediCal pnnciples
and techmques. The
first chapter, "Understandmg the Human Body",
compnses eleven sections on modern anatomy and one on the tradltlonal
Chmese med1cme's v1ew of the human body. Of the seven chapters m
the book, one 1s fully ded1cated to "Chmese MedJCmal Plants" although
there are mstruct10ns on the use of herbal medJCmes and tradltlonal
therapeutiC techmques such as the paed1atnc T'uz-na massage and acu-
puncture throughout the book.
Among the duties of barefoot doctors are: educatmg thetr rural com-
mumtles not only on hygtene and stmple preventive measures but also
on the health poltctes promulgated from Betjmg; vaccmatlons and control
of infectious dtseases; keepmg ep1demiologtcal records; and emergency
or "prelimmary" medtcal treatment, but they must "refer d1fficult cases
to designated hospitals promptly" (Chen Zhongwu, 1984: 112-13). These
government efforts to provide reliable pnmary health care to the rural
areas by
combmmg tradmonal Chmese med1cme and basiC modern
med-
Ical trammg have been substantial and are commended even by notable
members of the modern med1cal system such as Professor L!U Shi-Jle,
Professor of Public Health at Be1jmg Medical College (Liu, 1985: 88-89).
In urban areas the merger of the two systems ts just as visible. There
are both modern and tradltlonal medtcal practitioners m hospitals offenng
traditional Chmese medtcme, as md1cated m Table 2 1. Most of the de-
partments m general hospitals are dediCated to modern mediCal specialities
such
as obstetncs and gynaecology, otorhmolaryngology, dermatology and paed~atncs, and are staffed by modern doctors. But most general (city)
hospitals
around the country have wards dedtcated to traditional Chmese
medJCme; and over 4,
700 modern doctors had been "orgamzed to
learn traditional Chmese medJCme for a penod of at least 2 years" (Chen
Zhongwu, 1984: 86).
In addition to the front-ltne barefoot doctors m rural areas and the
modern med1cal doctors who take extra courses m traditional Chmese

Mamage of Cont'enzence m Chma 33
medtcme, two other mtermedtate categones of mediCal personnel are
tramed. By 1985 twenty-three colleges of traditional Chmese med1eme
had been estabhshed by the government to provtde trammg for over
25,000 undergraduate students nation-wtde. Students are admttted to
these colleges after passmg an entrance exammation upon thetr com-
pletion of "semor or mtddle school"; they must then undergo a total of
five years of traimng wh1eh mclude four years of Chmese matena medtca
and one year of hospital mternshtp. There 1s an offiCial gutdeline stlpulat-
mg that admtsstons to colleges of tradltlonal Chinese med1eme "should
represent 20 per cent of the total admtsstons to the htgher level schools
of medtcme and pharmacy" (Chen Youbang, 1985: 37). Postgraduate
degrees m
tradttlonal Chmese
med1eme at the Masters and doctorate
levels are also conferred now by "19 colleges of tradmonal medicine and 3
tradltlonal
medtcme research
Institutes" (1985: 38). The other mtermediate
category of mediCal personnel IS the "mtddle-grade" pnmary health care
workers
who attend a three-year course
wtth a combmed curriculum
compnsmg "tradtttonal medtcal theory and practiCe", "anatomy, physiology,
biochemistry, miCrobiOlogy, phatology", and other subjects of modern
medicme. The modern med!Cme part takes up "about one thtrd" of the
course (1985: 38).
The merger pohcy Initiated m 1950 has been remforced and im-
proved over the years. A few examples of such effort w1ll sufftce. In 1954
the National Committee of the Chmese People's Pohttcal Consultative
Conference sponsored an academic forum mvolving tradltlonal Chmese
physicians and modern doctors; m 1955 the Academy of Traditional
Chinese Med1eme was set up and 1t held 1ts first course on trad1t1onal
Chmese med1eme for modern doctors the same year; m 1959 the Mm1stry
of Pubhc Health mstructed all med1cal personnel to study a People's
Dmly editonal entitled "Implement Conscientiously the Party's Pohcy
toward Trad1t1onal Chmese Med1cme"; in 1962 the Mmistry of Pubhc
Health sponsored a forum on Education Work m Colleges of Traditional
Chmese Med1eme; m 1965 the State Science and Technology Commis-
Sion set up a tradmonal Chmese med1cme and pharmacology group and
a d1scuss10n was held on the outcome of the combined use of tradltlonal
and modern medicine m the treatment of bone fractures and d1phthena
cases; between December 1971 and February 1972 a national conference
Was held on the combmed use of tradtttonal Chmese medicme and

34 Stella R Quah and L1 ]mg-wel
modern med1cme; a national conference on the same theme was convened
by the Mm1stry of Health m 1977 and 1979; in 1979 the All-Chma
AssoCiation for Traditional Chmese Medicine was set up under the spon-
sorship of the Mm1stry of Public Health and the Chma AssoCiation for
Science
and Technology; the same year a symposiUm on acupuncture
anaesthesia was held m BeiJing; and m 1982 the Mm1stry of
Public Health
orgamzed a conference m Shijlazhuang on the mtegration of traditional
and modern med1cme (Chen Ha1feng and Zhu, 1984: 429-42).
More Importantly m terms of policy-makmg was the resolution passed
by
the
fifth plenary se~s1on of the fifth National People's Congress on
4 December 1982. It stipulated m Article 21 of the Constitution of the
People's Republic of Chma that the state should develop both modern
med1cme and traditional Chmese medJCme m 1ts effort to 1mprove the
health care system m the country. Accordmgly, the State Counol rati-
fied the foundation of a State General Bureau of Traditional Chmese
MedJCme to oversee the application of traditional Chmese medtcme as
well as
the merger w1th modern med1cme. Furthermore, government
grants for the development of traditional Chmese med1cme contmue
and have mcreased consistently every year.
The assessment of the merger
IS difficult cons1denng the sheer pro-
portions of users and providers of med1cal serviCes and the Immense
terntory that such serviCes must cover. Fortunately, mternal appraisals
have
become mcreasmgly objective. For example, m h1s report to a World
Health Orgamzation semmar m 1985, the D1rector for
Soence and Tech-
nology at the Department of Traditional Chmese MedJCme of Chma's
Mm1stry of Public Health md1cated that It was "too early" to expect
complete mtegration of the modern and tradJtJOnal systems of med1cme
m
Chma and that
Generally
:,peakmg, tradmonal med1cme IS used to the greate;,t extent
(about 40% of the cases) m pnmary health care and much less m
ho:,pital practice, except m the traditional hospital-; and wards Most of
the general hospital-; me modern med1cme and add some traditional
med1cme Accordmg to the condltlon, diseases are treated with a tradi-
tional, We;,tern, or mtegrated approach. There 1s much overlap,
where one sv;,tem Is tned f1r:,t and then changed for the other In effect,
there are now three systems. tradltlonal, We;,tern and mtcgrated (Xu,
1985. 15)

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AOTUS.
APEIBA.
APHELANDRA.
APHELEXIS.
APHIDES.
APHYLLANTHES.
APICRA.
APIOS.
APLECTRUM.
APOCYNUM.
APONOGETON.
APPLE.
APPLE-BLOSSOM WEEVIL.
APPLE MUSSEL SCALE.
APPLE or CODLIN GRUB.
APRICOT.
AQUATIC PLANTS.
AQUILEGIA.
ARABIS.
ARACEÆ.
ARACHIS.
ARALIA.
ARALIACEÆ.
ARAUCARIA.
ARBOR.
ARBORETUM.
ARBUTUS.
ARCTOSTAPHYLOS.
ARCTOTHECA.
ARCTOTIS.
ARDISIA.
ARDUINA.
ARECA.
ARENARIA.
ARENGA.
ARETHUSA.

ARGANIA.
ARGEMONE.
ARGIYREIA.
ARGYROXYPHIUM.
ARISÆMA.
ARISARUM.
ARISTEA.
ARISTOLOCHIA.
ARISTOTELIA.
ARMENIACA.
ARMERIA.
ARNEBIA.
ARNICA.
ARPOPHYLLUM.
ARRACACHA.
ARTABOTRYS.
ARTANEMA.
ARTEMISIA.
ARTHROPODIUM.
ARTHROSTEMMA.
ARTICHOKE, GLOBE.
ARTOCARPUS.
ARUM.
ARUNDINARIA.
ARUNDO.
ASARUM.
ASCLEPIAS.
ASCYRUM.
ASHES.
ASIMINA.
ASPALATHUS.
ASPARAGUS.
ASPARAGUS BEETLE.
ASPASIA.
ASPERULA.
ASPHALT.

ASPHODELINE.
ASPHODELUS.
ASPIDISTRA.
ASPIDIUM.
ASPLENIUM.
ASSONIA.
ASTARTEA.
ASTELMA.
ASTEPHANUS.
ASTER.
ASTERACANTHA.
ASTILBE.
ASTRAGALUS.
ASTRANTIA.
ASTRAPÆA.
ASTROCARYUM.
ASTROLOMA.
ASYSTASIA.
ATALANTIA.
ATHAMANTA.
ATHANASIA.
ATHRIXIA.
ATHROTAXIS.
ATRAGENE.
ATRIPLEX.
ATTALEA.
AUBERGINE.
AUBRIETIA.
AUCUBA.
AUDOUINIA.
AULAX.
AURICULA.
AVENA.
AVENUES.
AVERRHOA.
AZALEA.

AZARA.

BABIANA.
BABIANA.
BACCHARIS.
BACKHOUSIA.
BACTRIS.
BACULARIA.
BÆRIA.
BALBISIA.
BALCONY.
BALSAM.
BALSAMODENDRON.
BAMBUSA.
BANISTERIA.
BANKSIA.
BAPHIA.
BAPTISIA.
BARBACENIA.
BARBAREA.
BARKERIA.
BARKLYA.
BARLERIA.
BARNADESIA.
BAROSMA.
BARRINGTONIA.
BARTONIA.
BASELLA.
BASKETS.
BASSIA.
BASS. or BAST MATS
BATATAS.
BATEMANNIA.
BAUERA.
BAUHINIA.
BEAN BEETLE.

BEANS.
BEAUCARNEA.
BEAUFORTIA.
BEAUMONTIA.
BED.
BEDFORDIA.
BEET.
BEETLES.
BEFARIA.
BEGONIA.
BELLEVALIA.
BELLIDIASTRUM.
BELLIS.
BELLIUM.
BELOPERONE.
BENTHAMIA.
BERARDIA.
BERBERIDOPSIS.
BERBERIS.
BERCHEMIA.
BERGERA.
BERKHEYA.
BERTOLONIA.
BERZELIA.
BESCHORNERIA.
BESLERIA.
BESOM.
BESSERA.
BETA.
BETULA.
BIARUM.
BIDENS.
BIEBERSTEINIA.
BIFRENARIA.
BIGELOVIA.
BIGNONIA.

BILLARDIERA.
BILLBERGIA.
BIOPHYTUM.
BIRDS.
BISCUTELLA.
BIVONÆA.
BIXA.
BLACK FLY or BEAN FLY.
BLÆRIA.
BLAKEA.
BLANDFORDIA.
BLECHNUM.
BLEPHARIS.
BLEPHILIA.
BLETIA.
BLUMENBACHIA.
BOBARTIA.
BOCCONIA.
BŒBERA.
BOILERS.
BOLETUS.
BOLEUM.
BOLTONIA.
BOMAREA.
BOMBAX.
BONATEA.
BONGARDIA.
BONNETIA.
BORAGO.
BORASSUS.
BORBONIA.
BORDERS, FLOWER.
BORONIA.
BORRERIA.
BOSCIA.
BOSSIÆA.

BOSWELLIA.
BOTHY.
BOTRYCHIUM.
BOUCEROSIA.
BOUCHEA.
BOUGAINVILLEA.
BOUSSINGAULTIA.
BOUVARDIA.
BOWENIA.
BOWIEA.
BRACHYCHITON.
BRACHYCOME.
BRACHYLÆNA.
BRACHYOTUM.
BRACHYSEMA.
BRACHYSPATHA.
BRACHYSTELMA.
BRAHEA.
BRAINEA.
BRASSAVOLA.
BRASSIA.
BRASSICA.
BRAVOA.
BREDIA.
BREXIA.
BRICKS.
BRILLANTAISIA.
BRIZA.
BROCCOLI.
BRODIÆA.
BROMELIA.
BROMHEADIA.
BRONGNIARTIA.
BROSIMUM.
BROUGHTONIA.
BROUSSONETIA.

BROWALLIA.
BROWNEA.
BROWNLOWIA.
BRUCEA.
BRUNFELSIA.
BRUNIA.
BRUNONIA.
BRUNSVIGIA.
BRUSSELS SPROUTS.
BRYA.
BRYANTHUS.
BRYONIA.
BRYOPHYLLUM.
BUCKLANDIA.
BUDDING.
BUDDLEIA.
BUDS, FLOWER.
BUETTNERIA.
BULBINE.
BULBOCODIUM.
BULBOPHYLLUM.
BULBS.
BUNCHOSIA.
BUPHTHALMUM.
BUPLEURUM.
BURBIDGEA.
BURCHARDIA.
BURCHCHELLIA.
BURLINGTONIA.
BURNET.
BURSARIA.
BURSERA.
BURSERACEÆ.
BURTONIA.
BUTEA.
BUTOMUS.

BUXUS.
BYRSONIMA.

CABBAGE.
CABBAGE CATERPILLARS.
CABBAGE POWDERED-WING.
CABOMBA.
CACALIA.
CACOUCIA.
CACTEÆ.
CACTUS.
CÆSALPINIA.
CAJANUS.
CAKILE.
CALADENIA.
CALAMAGROSTIS.
CALAMINTHA.
CALAMUS.
CALANDRINIA.
CALANTHE.
CALATHEA.
CALCEOLARIA.
CALDCLUVIA.
CALEANA.
CALENDULA.
CALIPHRURIA.
CALLA.
CALLIANDRA.
CALLICARPA.
CALLICOMA.
CALLIGONUM.
CALLIPRORA.
CALLIPSYCHE.
CALLIRHOE.
CALLISTEMON.
CALLISTEPHUS.

CALLITRIS.
CALLUNA.
CALOCHILUS.
CALOCHORTUS.
CALODENDRON.
CALOPHACA.
CALOPHANES.
CALOPHYLLUM.
CALOPOGON.
CALOSCORDUM.
CALOSTEMMA.
CALOTHAMNUS.
CALOTROPIS.
CALTHA.
CALYCANTHUS.
CALYCOPHYLLUM.
CALYCOTOME.
CALYPSO.
CALYPTRANTHES.
CALYPTROGYNE.
CALYSTEGIA.
CALYTHRIX.
CAMASSIA.
CAMBESSEDESIA.
CAMELLIA.
CAMELLIA.
CAMPANULA.
CAMPANUMÆA.
CAMPHORA.
CAMPTOPUS.
CANARINA.
CANARIUM.
CANAVALIA.
CANBIA.
CANDOLLEA.
CANELLA.

CANISTRUM.
CANKER.
CANNA.
CANNABIS.
CANSCORA.
CANTUA.
CAPPARIS.
CAPSICUM.
CARAGANA.

Transcriber notes:
P. 14. 't rminal' under Aciotis, changed to 'terminal'.
P. 21. 'Ternstroemiaceoe' changed to 'Ternstroemiaceæ'.
P. 27. 'producing fronds', fronds is usually in italics. Changed.
P. 27. 'A synonymn of A. venustum.', changed 'synonymn' to
'synonym'.
P. 41. 'deeply chanelled', changed 'chanelled' to 'channelled'.
P. 41. 'A. Wislizeni ... which is under 2ft. broad'; should 'broad' be
'long'? Left as a query.
P. 49. A Scorodoprasum. 'Europ' changed to 'Europe'.
P. 53. A. ageratoides. 'receptable" changed to 'receptacle'.
P. 87. 'surface is punctuate', changed 'punctuate' to 'punctuated'.
P. 87. 'of less than than', taken out one 'than'.
P. 134. A. umbrosum. 'laceolate' changed to 'lanceolate'.
P. 162. 'Caraccas', changed to 'Caracas'.
P. 171. 'browish when matured.', changed 'browish' to 'brownish'.
P. 174. 'numerous arge round', changed 'arge' to 'large'.
P. 190. 'part the day' changed to 'part of the day'.
P. 190. 'Rio Janeiro, 1825.' changed to 'Rio de Janeiro, 1825.'
P. 210. 'Caraccas', changed to 'Caracas'.
P. 213. 'Syn. B Joinvillei, B. pitcairniæfolia.', changed 'Syn.' to
'Syns.'
P. 222. 'There is a is a variety', removed extra 'is a'.
P. 235. 'petioles sheating' changed to 'petioles sheathing'.
P. 259. 'CAPSIDIUM' is 'CAMPSIDIUM' in another volume.
Changed.
Fixed various punctuation.

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