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本文试图探讨随着赤脚医生推动西医西药广泛进入中国农村的同时,他们是如何实现了乡村医疗卫生的制度化。本文认为,1950年代联合诊所的出现以及县乡二级医疗卫生体系的建立对于农民求医行为的影响依然是有限的。家仍然是求医的主要场所,医疗社区尚不成熟,乡村社区内外的医疗协调互助机制并未形成。这种乡村医疗世界的格局随着1968年赤脚医生的出现而得以改变。赤脚医生创办的合作医疗站使得县乡二级医疗体系而下延伸从而确立了三级医疗体系。它不仅强化了以各公社为基础的医疗社区,而且第一次在乡村确立了医疗技术等级体制下的协调和互助机制。依赖于转诊和合作医疗制度,赤脚医生使得农民的求医行为实现了从大队医疗站、公社卫生院到县医院的延伸和分层,从而实现了家到医院的转移。本文进一步指出,大队医疗站和县医院在这个过程中不断扩展,而处在三级医疗卫生体系中第二级的公社卫生院则急剧衰落。这种变化使得三级体系演化成为“哑铃型”结构,在这种结构中赤脚医生取代了公社卫生院从而主导了乡村医疗社区。这种格局一直延续至20世纪初期,并成为乡村医疗卫生体制危机起源的一个重要因素。
This article attempts to explore how Barefoot doctors institutionalized rural medical and health care while promoting the widespread entry of Western medicine into Chinese rural areas. This paper argues that the emergence of joint clinics in the 1950s and the establishment of secondary health care systems in counties and townships still have limited impact on peasants’ seeking medical treatment. Home is still the main site for medical treatment. The medical community is not yet mature, and the mechanism for medical coordination and mutual assistance within and outside the rural community has not been formed yet. The pattern of this rural medical world changed with the appearance of a barefoot doctor in 1968. A cooperative medical station founded by barefoot doctors led to the extension of the county-level two-tier medical system to establish a three-tier medical system. It not only strengthened the medical communities based on communes, but for the first time established the mechanism of coordination and mutual aid under the medical technology hierarchy in rural areas. Relying on the referral and cooperative medical system, Barefoot doctors enabled farmers to seek medical treatment from the brigade medical stations, commune hospitals to the county hospital extension and stratification, in order to achieve the transfer of home to the hospital. This paper further points out that the brigade medical stations and county hospitals have been expanding in this process, while the commune hospitals located at the second level of tertiary health care system have declined dramatically. This change has led to the evolution of the tertiary system into a “dumbbell-shaped” structure in which barefoot doctors replaced the commune hospitals and dominated rural medical communities. This pattern continued into the early 20th century and became an important factor in the origins of the rural health system crisis.