Rockefeller Foundation’s Global Health and China’s Modern Health Development

The Rockefeller Foundation (RF) was the first private organization to have systematically envisioned and practiced public health as a world system. The RF exerted extensive influence in disseminating medical science, public health practice and policies in the world. It set up similar public health institutions in many countries by working with national and colonial governments, empires of Europe and the United States, and the League of Nations Health Organization. This article focuses on the RF’s role in the development of modern health in China. It situates the discussion in the larger context of RF’s involvement in Asia. The RF made significant achievements in China primarily through the mechanisms of the International Health Board, the China Medical Board, and the extraordinary capabilities of John B. Grant. Drawing on archival data and recent research, this article examines the interactive work between RF officials, Chinese health professionals, and the Chinese government in standardizing medical science education and the training of health professionals by means of establishing Peking Union Medical College and the health demonstration stations. It shows how these programs and institutions ultimately helped shape up the creation of a national health system in China. This study sheds light on the long-term legacy of the RF in China and the implications of state medicine and medical efficiency for current global public health.

Resumen: La Fundación Rockefeller (FR) fue la primera organización privada en haber imaginado y practicado sistemáticamente la salud pública como un sistema mundial. La FR ha tenido una gran influencia en la difusiónde la ciencia médica, las practices y las políticas de salud pública en todo el mundo. Estabeleció instituciones de salud pública similares en muchos países, trabajando con gobiernos nacionales y colonials, imperios Europeos y estadunidenses y la Organización de la Salud de la Liga de Naciones. Este artículo se centra en el papel de la FR en el desarollo de la salud moderna en China. Sitúa la discusión en el contexto más Amplio de la participación de la FR en Asia. FR ha logrado importantes logros en China, principalmente a través de los mecanismos de la Junta Internacional de Salud y las extraordinarioas capacidades de John B. Grant. Basado en datos de archive e investigaciones recientes, este artículo examina el trabajo interactivo entre los funcinários de la FR, los profesionales de la salude chinos y el gobierno chino en la estandarización de la enseñanza de las ciencias médicas y la formación de los profesionales de la salud a través del Peking Union Medical College y de las estaciones de demonstración de salud. Muestra cómo estos programas e isntituciones ayudaron en última instancia a dar forma a la creación de un sistema nacional de atención médica en China. Este estudio arroja luz sobre el legado a largo plazo de la FR en China y las implicaciones de la medicina estatal y la eficiencia médica para la salud pública mundial actual. Palabras clave: China. Estaciones de salud. Sistema de salud. PUMC. Fundación Rockefeller.

Introduction: Initial Programs in Asia
The Rockefeller Foundation was the first global force to have envisioned and practiced systematically a world system of public health in the first half of the 20 th century. It worked with governments (local, national or colonial), non-governmental organizations (social, philanthropic, missionary and professional), empires of Europe and the United States, and the League of Nations Health Organization (LNHO) in developing a global public health system.
In the process, the RF exerted extensive influence in the realms of medical science, public health professionalization, public health practices and policies in many countries. The RF gained the global dominance through programs established by the International Health Board (IHB). The IHB was initially created as the International Health Commission (IHC) on June 27, 1913, with the "promotion of public sanitation and the spread of knowledge of scientific medicine" as its mission. ii The IHC became the International Health Board in 1916 and the International Health Division (IHD) in 1927. The International Health Board worked with local governments to build medical schools and health demonstration stations to introduce modern medical science, sanitation, hygiene, and disease-prevention around the world. It originally planned to operate "in Latin America, the Orient, and the empires of Britain, France, and the Netherlands," but by the time it was closed in 1951, the International Health Division had run health programs in over 80 countries on every continent. John Farley pointed out that the working patterns of the IHD seemed to be repeated everywhere: first it would undertake a survey and make recommendations; then it would establish schools of hygiene to train key personnel; and finally it would finance the development of a public health service by the means of demonstration health units. iii The RF's strategy in creating a global health system was purported to use its pioneering programs in each country to stimulate changes in government policies and programs in regard to public health.
The RF's activities in Asia followed the pattern that Commission's survey led to the RF's deep involvement in China in the following decades, starting with the formation of the China Medical Board to oversee its endeavors in China (CHINA MEDICAL COMMISSION, 1914). In Sri Lanka, the British planters used tens of thousands of coolies from southern India and kept them in terrible living and working conditions. The coolies lived in poorly constructed small huts, where the surrounding grounds were covered with trash and filth. Hookworm disease thrived among the laborers on plantations with over 90 percent of them infected with the disease (HEWA, 1995, p. 39). The RF's antihookworm program started on the plantations with reluctant cooperation of the British colonial government and open resistance of the British planters. The British colonists viewed the Rockefeller presence as interference with their governance and incursion into their medical authority. After six years of treatment, the program failed to reduce hookworm among the laborers on the plantations. The IHB field officers drew lessons and changed their strategy in health work. They began to build health units in villages and towns in the 1920s to tackle public health problems through seeking collaboration with local people, community leaders and the colonial government. A key strategy of the health unit program was to identify the most common health problems in each health unit area and control them through improving sanitation, health education, immunization and treatment with the help of local communities (HEWA, 2011). The health unit system or the health station system, which was first used by the RF in the US south in the 1910s, became an effective model that was introduced to other countries to promote public health and disease control.
In the 1920s, the Rockefeller Foundation established rural health programs in the Dutch East Indies (Indonesia) by building health demonstration stations. The Dutch colonists, like their British counterparts, viewed the Rockefeller presence as a challenge to their authority and rarely collaborated. The Dutch colonists also excluded Javanese medical professionals from medical practice through discriminative examination systems. The Dutch medical exclusion of the Javanese turned out an opportunity for the RF field officers to recruit the Javanese to work at the IHD-funded health demonstration stations. The young Javanese medical workers educated rural people about health and hygienic practices for disease prevention. Some of them served as health managers and operatives. These experiences helped them become pioneers of Indonesian health leaders who later played important roles in Indonesia's independent movement from the Dutch colonial rule and the building of a national health system (POLS, 2018). The Rockefeller rural health programs, as Eric Stein argues, resonated with the anticolonial nationalist call for public education of health in order to achieve the goal of "healthy people, strong nation" (STEIN, 2012).
The RF began to extend influence into Japan in the 1920s after it had established the Peking Union Medical College in China as the outpost of modern medical science in Asia.
Different from many other Asian countries, Japan had followed the German model of bacteriological research as the foundation of public health and disease prevention during its modernization of medicine and public health after Meiji Restoration. When the RF wanted to break into Japan's established health system to assert American influence, it encountered the resistance of an established system that had already been operating in Japan. The RF was able to make initial moves into Japan's health system by offering fellowships to Japanese medical and health scholars for advanced training in public health at prominent American universities such as the Johns Hopkins. The RF viewed Japan's public health practice as good in laboratory research but poor in application to the society. American training was purported to help Japan tackle its deficiencies. The RF, using its influential prestige in world health affairs, negotiated with the Japanese government for the approval of building health institutions. Ultimately, two health demonstration stationsone in urban Tokyo and the other in a rural area outside Tokyo and the Institute of Public Health were built in Japan in the 1930s. Those institutions promoted American-style health research and practice but had limited impact on Japanese health system before World War II. They continued with a new power of influence to shape up Japan in American image after the war when Japan was defeated and occupied by the United States.

Influence on China's Medical Education and Public Health
The RF had the most extensive reach in shaping China's modern medical education and public health, compared to its work in other countries. It created the China Medical Board to oversee its enterprise in China, particularly the operation of Peking Union Medical College.
In the training of health profession and building health institutions, the RF exerted more profound influence than any other external organizations in China. The following sections will discuss several aspects of RF's work and analyze their roles in China's modernization of health profession and the creation of a national health system. They include the building of Peking Union Medical College, the campaign for the study of medical science, the building of urban and rural health stations, and the creation of a national health administration with state medicine as the framework. The extraordinary influence of the RF in China happened in the larger global context of interwar years when private philanthropies became more active in international affairs and when state took health responsibilities as an important part of government function.
The specific programs and broad engagement of the RF showed its prestige and influential power in standardizing medical knowledge production, training professional expertise, directing public health practice, and setting up modes of health administration in the 1920s-1940s.
Studies of the RF's enterprise in China have previously concentrated on the highprofile Peking Union Medical College, with less attention to its broader influence in China's health profession, health programs and policies, and national health system. Recent research on the RF has extended into those areas in addition to RF's involvement in rural reconstruction, and the unique role of John B. Grant in all of these (BU, 2012b(BU, , 2014. As the following discussion shows, the RF's various initiatives and programs were inter-related blocks that worked ultimately towards the creation of a national health system in China.

Peking Union Medical College
The RF's first major accomplishment in China was the building of Peking Union Medical College (PUMC) with rigorous standards of medical science education. It was a worldclass medical institution modeled after the Johns Hopkins University School of Medicine. The RF made the PUMC an American "outpost of modern medicine in the Far East" to impress William H. Welch and Simon Flexner, the giants in American medicine, sat on the China Medical Board to set the criteria for the new PUMC in regard to faculty, students, and research as well as the language of instruction. Medical curriculum and length of courses were all designed with the best of American medical schools as the prototype. In order to guarantee the quality of students, PUMC created its own pre-medical school to strengthen science courses on physics, chemistry and biology to prepare the students for medical college education.
Teaching was changed from Chinese to English language during the transition from missionary to RF-sponsored medical education. Applicants for PUMC must first pass the English proficiency test, which limited the access of PUMC only to those who had prior exposure to Western influence and education, namely, missionary and elite schools. CMB officials justified their decision on English as the language of instruction with the claim that "it is impossible to train students properly in modern medicine through the medium of this tongue [Chinese]" (FERGUSON, 1970, p. 25). Some educators, including missionaries, however, warned William Welch: "Chinese students taught medicine in English are likely to be out of touch with the people and will not advance Chinese medicine". v The CMB authorities, though fully aware that English language education would produce students out of touch with the Chinese masses, were nonetheless convinced that English instruction was necessary to keep rigorous standards of medical science. The requirement of English, along with the predominance of Americans on the faculty, defined PUMC's identity as a foreign institution in China, even though the college was housed in buildings of traditional Chinese architecture.
The PUMC began to admit students in 1919. By 1921, the year the college was officially dedicated, the total enrollment of students amounted to only thirteen. Following the standards set up by Welch and Flexner, the college introduced rigorous science studies and research in the fields of anatomy, chemistry, biology, physiology, pathology, bacteriology, surgery, medicine, material medica, ophthalmology, gynecology, and obstetrics. PUMC also established a hospital for the purpose of medical teaching and training, following the model of the Rockefeller Institute for Medical Research in the United States.
X-ray, this most advanced scientific instrument of diagnosis in the West at the time, was acquired by PUMC for research and medical practice. A radiology unit was created with Paul C. Hodges in charge. Hodges, who had received his medical training at Washington University and been working with X-ray diagnosis, was a master of radiological instrumentation. He made an "enduring contribution to the introduction of diagnostic radiology to China" (BOWERS, 1972, p. 142-143). He trained Xie Zhiguang (Chih-kuang Hsieh) at PUMC, who became the first Chinese radiologist and headed the radiology department at PUMC from 1928 to 1948. Moreover, Hodges built X-ray machines that were able to operate on various electrical supplies and conditions. These machines were purchased and used by about Western medicine. vii The CMB expected the Council to popularize Western medicine and to inspire students' interest in the study of medical science. The Council gave lectures on medical science, made medical presentations with follow-up exhibits, interviewed and corresponded with students, and arranged students' visits to local hospitals and medical schools of Western medicine. The Council even changed the topic of its annual national essay contest from "National Health and National Strength" to "Medicine as a Life Work." viii Eight scholarships of $100 (Mex.) each were established to award annually the freshman who won the first place in the entrance examination at eight medical schools (PETER, 1926, p. 229-230).
The China Medical Board, recognizing the importance of standardized Chinese translation of Western medical terms, made financial support for the translation of Western medicine into Chinese. As a field of knowledge, Western medicine had to be translated into Chinese language that would culturally make sense to Chinese people. Different groups such as missionaries and medical professionals had used different terms in their translation since the 19 th century. To bring standardization to medical terminology, the National Medical

Innovative Training of Health Professionals
The RF did not directly engage in hygiene and disease control in China in the beginning, presumably for the following reasons: (1) systematic protection of public health was a government function; (2) confidence in scientific medicine was not sufficiently widespread to insure Chinese people's cooperation for effective work; (3) the conditions in China to be dealt with, be it biological, social, or economic, were so different from those in the West that it was important to precede by a careful study of local conditions and proper adaptations; and (4) no sufficient numbers of highly trained personnel necessary for public health program was available (ADDRESSES AND PAPERS, p. 4). If these were the reasons for not taking on the preventive medical work in China, the RF certainly did not hesitate to conduct hygiene and disease control in Sri Lanka and Java at that time, where local conditions were not any better than in China. It was apparent that the RF had a different strategy in China. Up till 1920 the China Medical Board made little effort in popular education of preventive medicine and public health matters, even though a variety of local and professional organizations had engaged in these efforts since the early days of the 20 th century (BU, 2009b).
Pearce, director of the Division of Medical Education of the RF and acting director of the PUMC in 1920-1921, both made it clear to George Vincent, William H. Welch and Victor Heiser the need of hygiene education at PUMC. Pearce wrote that not only the internal "matters of quarantine, student and staff health and control of sanitation" for the college employees put much burden on the professor of medicine but also the external demand to help with "famine relief, plague in Manchuria, and…preparing for a possible typhus epidemic" in Chinese society compelled the PUMC to take men from the department of medicine to participate in such work. xi Pearce considered the engagement in public health services, though necessary, detrimental to the work of the department of medicine, because it prevented medical professors from doing their own work. As an advanced and best equipped medical institution in China, PUMC could not, however, "escape this responsibility in times of public calamity…. Every foreign institution is expected to do its share in order to help out the weak Chinese administration, and to decline to assist puts us in a bad light and weakens our prestige". Pearce continued that PUMC was already losing "valuable opportunities to impress upon the community its usefulness in the field of public health" and losing contact with government authorities because PUMC did not have a man to devote his entire time to hygiene work. xii With reports like these, the RF began to re-position itself in the matter of public health. Chongrui tried to set up a pilot midwifery program in rural Dingxian with a modern doctor of obstetrics and a young trained nurse, it did not work out. Rural people, who were used to childbirth delivery by older women with personal experiences, did not trust a young city girl of twenty-some as a midwife. Traditional social norms rendered a young woman unfitting for the job. Moreover, modern physicians and nurses in white uniforms appeared strange as outlandish aliens in rural settings, especially when white color symbolized death and mourning in Chinese traditional culture. Even when emergency of difficult labor occurred, the poor transportation conditions in rural villages would make it hard, if not impossible, for the doctor to arrive in time to provide help. Moreover, service fees of modern midwife cost a lot, compared to the token payment villagers gave to granny midwives. The high cost associated with the service of modern midwifery made midwives affordable only to the well-to-do people. In Dingxian, when Chen Zhiqian (Chen Chih-ch'ien, C.C. Chen) tried to train local nativesthe young female relatives of village grannies to be midwives, he failed to get their commitment to the practice of midwifery. Rural people did not think childbirth a medical matter but a joyful event of family affairs. Chen observed that when women were healthy, they had few abnormal labor (CHEN, 1936, p. 381-384).
The majority of babies in China were delivered by relatives who had birth experiences and knew personally what to do at a baby's birth. For instance, field investigations in early 1940s indicated that as high as 88 percent of births were not attended by any midwife, old or new type, but relatives in the Dingjia rural district of Bishan county of Sichuan province. xx Childbirth was a family matter of the female members who passed on the knowledge and experience of childbirth from mothers to daughters and from experienced women to new mothers. This finding, in addition to the Dingxian experience in the 1930s, shed light on the wrong assumption by national health authorities that high infant mortality was exclusively caused by granny midwives' lack of scientific knowledge of hygiene. Infant mortality was much higher in poor rural areas because of poverty and mal-nutrition. Health professionals, however, blamed infant mortality on the ignorance of old-style granny midwives. Their emphasis on scientific midwifery training with modern aseptic knowledge often excluded the attention to poverty, mal-nutrition and mother's health as factors of higher infant mortality.

Health Stations as Pilots of Public Health
Health stations as an experiment had the promise of achieving two major goals: (1) the study of local health conditions and (2)  started. The extraordinary experience of Dingxian has been well studied by scholars (HAYFORD, 1990;GAMBLE, 2011;CHEN, 1989).
Chen Zhiqian made significant achievements at Dingxian by training local peasant youths as health workers to provide service to their fellow villagers. Village health workers were a new phenomenon but highly successful because they came from village families and had the trust of people they were serving, unlike the health professionals from outside whom villagers tended to hold in suspicion and distrust. The intrinsic trust of one's own by the villagers made a huge difference in facilitating local health cooperation. Chen attributed his success in Dingxian to his earlier experience: "Xiaozhuang may have germinated the ideas I developed subsequently at Dingxian to train village health workers to take on some of these relatively simple tasks" (CHEN, 1989, p. 68-69). Building upon his program of training peasant health workers, Chen made further innovation in organizing a village-based three-tier health network that connected the village with the xian (county) health center and district health station via village health workers. The three-tiered organizational structure of rural health network overlapped the rural administrative structure. More importantly, Dingxian's health programs were well integrated in a general rural reform movement of education and agricultural improvement. Dingxian's success provided the Nationalist government ideas on how to design rural health.
Rural health stations caught the imagination of many Chinese reformist intellectuals.
Chinese scholar Liang Shuming, who was labeled the last Confucian, came to observe the Xiaozhuang experiment and then created a rural reconstruction experimental area in Zouping county of Shandong province (ALITTO, 1979). Chinese enthusiasm for experimental health stations gave John Grant more confidence in the usefulness of health stations to change China.
He worked with Hu Hongji, his former colleague at the Beijing health station but now the Health Commissioner of Greater Shanghai, on a plan to build a rural health demonstration and a school health demonstration in Shanghai. Their proposal to the RF described the health demonstrations as collaborative projects of the IHD and the Health Bureau of Greater Shanghai. The school health demonstration did not work out due to lack of personnel. xxii The rural health demonstration was built as Gaoqiao health station, with the Harvard-trained Li Ting-an as director.
Gaoqiao was a rural town about 12 miles from Shanghai city center, covering an area of more than two hundred square li (half a km) with a population of 33,959. It sat on the east bank of Huangpu River and the south bank of Yangtze River, with about 200 villages surrounding the Gaoqiao town. The main reasons for choosing Gaoqiao as the site of a health demonstration area were: (1) it was rural but close to the city center, with various small businesses and merchants, and had better economic and literate conditions with 40 percent literacy rate compared to the national literacy rate of 10 percent at the time; (2) it was politically and administratively stable; (3) it had good cooperation between locals and police; and (4) the medical school of the Central University on the other side of the river could make good use of it for teaching purposes. xxiii Gaoqiao station, like many others, was destroyed by the Japanese in 1937 when Japan began the full-scale invasion war of China.
Gaoqiao health demonstration station followed the model of Beijing health station in conducting vital statistics collection, communicable disease control, and public health education, but the main activities were medical service. Health surveys showed that gastrointestinal diseases, malaria, rabies, tuberculosis, syphilis, smallpox, leprosy, puerperal sepsis and infections of the newborn were prevalent. The station offered daily medical service from morning till afternoon with surgical, medical treatment, gynecological obstetrics and pediatric clinics. The first quarter report of Gaoqiao station showed that only 1281 patients out of a population of 34,000 received medical services. Local people did not seem interested in the medical service and health demonstration. Different from Dingxian health programs, Gaoqiao did not train local villagers as health workers but relied on medical professionals from the city to provide medical service, which the locals apparently distanced from.
Of more significance in Chinese medical history was the invention of a traveling clinic at Gaoqiao station in 1929 (Figure 1). It was the first mobile clinic in China, designed to give smallpox vaccinations to villagers who did not come to the health center for service. The traveling clinic was made of two wheel-barrows that carried a doctor, a public health nurse and a sanitary policeman (see the picture). Their medical kit included vaccines, medical knives, antiseptics, other necessary medical supplies and health education pamphlets. The traveling clinic reached more people for vaccination, but only small numbers of people accepted vaccines and came for treatment at the health station over the years. The lack of interest on the part of the peasants indicated that rural people were still suspicious of modern medicine brought to them by external health authorities. They were reluctant to embrace vaccines and biomedical technologies which they knew very little about. Instead, they were used to using traditional Chinese medicine. The station's work proved rather ineffective among the local people, despite various efforts. Health stations as a method of studying local health conditions and introducing Western medical service continued to attract the attention of Chinese modernizers. More than 17 health centers/stations were established during 1929-1934 in six coastal provinces and the cities of Beijing and Shanghai. Surveys of the health stations were conducted to examine their effectiveness in meeting the designed goals. Survey reports in 1934 criticized that the majority of health stations were ineffective in providing health service to local population (LI, 1934;PENG, 1934). They also stated that the major problem was China's lack of competent technical personnel of health. Local officials, however, disagreed and argued that the main problem for the inadequate health service was poverty and lack of resources. Health professionals continued to argue, along with John Grant's repeated emphasis, that recruiting and training of health experts were of utmost importance for health service, while they ignored the larger socioeconomic factors such as poverty and health resources. Their opinions significantly influenced the Nationalist government's health policies.

Building a National Health Administration System
The RF's ultimate influence was the creation of a national health system in China. All In my opinion the best way to go about it is to consolidate P H work round a central focus either at Peking or Shanghai, preferably the former, making a model station from which graduate students would learn the proper way of working and then return to their various cities and establish Municipal Public Health. Then when China becomes purged of its present misrule and has a National Government you could link up these municipal schemes and weld them into a National service comprising not only municipal schemes but also a maritime quarantine service. xxvi Stampar who came to China to help build a national health system (BOROWY, 2009a). China was one of many countries in the inter-war years that the LNHO, upon request, helped with health reforms and establishing institutions of a national health system (BOROWY, 2009b).

Conclusion
The RF's activities in China reflected its global vision of building medical colleges and public health institutions as agents of change. The architects of RF's global vision were convinced of the power of medical science in improving people's lives by combatting diseases and reducing human sufferings. More importantly, they saw science as an effective means to solve health problems of humankind while enlightening people and transforming societies. The RF, especially the IHD, worked at the intersection of philanthropy, colonial powers, local and national governments to expand medical science and public health across the world, making the RF the most outreaching force to shape the global health system in the first half of the 20 th century. The story of the RF has been told extensively, with studies ranging from high praise to harsh criticism (BROWN, 1979;FOSDICK, 1952;BULLOCK, 2011). The studies, however, often glossed over the complex relations within the RF, such as the tensions between medical and health specialists in the field work and the global strategists at the New York headquarters.
Collaborations as well as tensions between the RF personnel and local governments, medical groups and social civic organizations in different countries were often lost in the narratives of philanthropy and imperialism. Recent studies of the RF in various Asian countries shed light that de-colonization movements made use of medical science and public health programs that the RF initially introduced to suit their needs and beliefs in the post-independent reconstruction of their countries into modern nations, a legacy that was far beyond the original intention and imagination of the RF officers. Baoshan, and Yang Chongrui, became leaders of important medical institutions. They were strong advocates of state medicine and public health. The ideas of state responsibility for public health and preventive medicine encountered an encouraging environment when those concepts were transformed into new practices for people's health in socialist China. Not only was preventive medicine emphasized as the first priority of national health policy and given an "adequate place in general education" (Grant's wish in the 1920s), medical service for all people also became a fundamental national policy as well. By the end of 1965, all 29 provinces had established "anti-epidemic disease stations with analogous structures for the railway, mining industry, and large enterprises" (BANGDIWALA et al., 2011, p. 208) . Moreover, although traditional Chinese medicine was promoted and widely used, public health education emphasized the biomedical model on "epidemiology, school hygiene, occupational hygiene, food hygiene, environmental hygiene and radiation hygiene" (BANGDIWALA et al., 2011, p. 209).
The PRC government inherited from the Nationalist government the national health administrative structure, and built upon it to strengthen health institutions and expand basic healthcare services to every corner of Chinese society. Health centers and clinics were set up in vast rural towns and villages to benefit the peasant population under a socialist health system (BU, 2017;LUCAS, 1980). "Barefoot doctors" worked as paramedics in the countryside. They were a new medical force for people's health in rural China, but the prototype can be traced back to the rural health workers that Chen Zhiqian trained in Dingxian in the 1930s. Chen explained that the Chinese government "adapted the ideas developed at Dingxian to great advantage in building a nationwide rural health care system after 1958" (CHEN, 1989, p. 36).
The barefoot doctors, like the rural health workers three decades earlier, originated from the village and served their fellow villagers after medical training. They not only used Chinese traditional medicine but popularized the use of Western medicine as well (FANG, 2012). After attending short training programs that were often followed up with update workshops, they became the primary health force to provide basic medical services and health education to the peasants, mediating between the state medical system and rural health care. xxx The free and low-cost healthcare system developed in the 1950s-1970s significantly applied preventive medicine in the efforts to achieve medical efficiency as well as the control and eradication of major epidemic diseases, such as smallpox, plague, cholera, typhus, typhoid, polio, kala-azar, filariasis, schistosomiasis, tuberculosis and malaria. China's low-cost healthcare of state medical system with emphasis on preventive medicine was hailed a great success model for many countries.