This book's title refers to a poem written by Mao Zedong in 1958. The God of Plague is schistosomiasis, a tropical disease which, in 2013, affected almost 300 million people around the world. Schistosome worms alternate parasitism of humans and freshwater snails, with aquatic larval stages in-between. Untreated heavy infections cause fatigue, anaemia, growth stunting, sometimes neurological disorders, and can be fatal. Negative impacts on the productivity of agricultural workers have been documented. An effective drug was introduced in the 1980s, but control remains challenging, requiring action at multiple points of the parasite's lifecycle and touching on aspects of personal hygiene, sanitation and water supply. Throughout much of the 20th century treatment was less effective and many campaigns came to nothing. John Farley's Bilharzia (Cambridge University Press, 1991), the only book-length investigation of these attempts, is an essay in the sociology of medical failure. The little optimism contained in that book was devoted to China. This is because China, which includes one of the largest endemic areas, is renowned for having successfully controlled schistosomiasis by means of a pioneering campaign in the 1960s and 1970s, characterized by draconian prevention measures enacted by the peasant masses exhorted by Mao. Thanks to Miriam Gross we now have a detailed reconstruction of this important episode in the history of public health, making a plausible case for correction of the abovementioned narrative.
Based on recently opened local archives, the study isolates three counties out of the 11 provinces involved in control activities. Heterogeneity in campaign performance is explored for each of its operational fronts: administration, financing, health education, prevention and treatment. Gross's main contention is that the campaign's undoubted success has been largely misunderstood: “Despite the predominant story line, villagers and local cadres did not support the campaign, and education efforts had minimal impact on fostering understanding or participation in prevention. … Nevertheless, the snail fever campaign succeeded … because of the heretofore unacknowledged work of the campaign's treatment arm” (p. 10). This re-evaluation of the role of treatment is not derived from pharmacological considerations. It comes instead from a rich characterization of the agency problems involved in the provision of control services, which overcomes the masses/technicians dichotomy to focus on the specific articulation of lay and professional elements in the campaign.
Compliance by local cadres was made indispensable by the decentralized campaign structure imposed by Mao shortly after its onset in the early 1950s. Engaged leaders lobbied for resources, promoted prevention activities and led by example. The transfer of urban physicians to rural areas, a key Maoist policy, meant that doctors had no reputation among prospective patients, further increasing the importance of cadre intermediation. A small minority of leaders bet their career on the campaign and succeeded in turning their counties into model sites, but these exceptions proved the rule. With little understanding of public health, no available evidence that schistosomiasis affected productivity, and salaries anchored to agricultural output, most local cadres initially perceived campaign tasks as harmful diversion of capital and labour. Here the virtuous circle became vicious: disengagement spilled over to villagers, to which many unfunded treatment costs were passed on, while doctors were left isolated.
Peasants, automatic compliers for Mao, nonetheless had their own doubts: they first found it bizarre to be sent to bury molluscs by the thousands – and then found it useless, as it became clear that nothing short of permanent control would displace the snail population from its equilibrium level. Entertaining pages document peasants' utter repulsion for “shit doctors” collecting stool samples for inspection. The logic of laboratory diagnosis was elusive, but the infringement of modesty was crystal clear. The Party targeted these cultural barriers with a battery of educational projects: many lay on the same ill-fated curve, where specific information obfuscated understanding but simpler language degraded the essential message. Without the modern concept of contagion, treatment of asymptomatic patients smacked of government fraud, and measures to avoid faecal contamination of drinking water appeared meaningless. However, peasants gradually learned that Western medicine was effective, and retrospectively cash, not culture, proved to be the binding constraint.
This leaky campaign engine was set in motion by Mao's cyclical injections of revolutionary fuel, which saturated the administrative structure, closing spaces of discretion and temporarily enforcing discipline. When these peaks deflated, the whole campaign collapsed, as happened after the Great Leap Forward – when schistosomiasis rebounded in epidemic proportions. During the Cultural Revolution, two crucial developments ensured a different outcome. First, treatment was fully subsidized. Second, urban physicians posted to rural clinics met with a new generation of rural barefoot doctors trained in what Gross labels “grassroots science.” With it, the Party brought basic statistics to young rural cadres and doctors, teaching them the language of bureaucracy it was censoring elsewhere. It was no substitute for proper medical training, but this requirement was met by interacting with urban doctors, who “disseminated scientific knowledge, trained local personnel, and treated massive numbers of people” (p. 34). The results were remarkable: with more than ten million cases in 1949, the campaign brought figures well below the million in late 1970s.
Epidemiological considerations have an obvious bearing on Gross's line of argument: snail control can temporarily lower reinfection rates but is rarely an effective stand-alone control tool. Treatment necessarily plays a major role in any successful campaign. However, historically it has often been insufficient. A full explanation of the Chinese case, Gross seems to suggest, must be found in the intricate social mechanics of the campaign, which managed to elicit sufficient human resources and coordinate control activities for long enough to kick entire disease foci beyond the ecological saddle-points that sustained them.
Purposeful or not, how did it happen? Education conceived as mere information transfer failed. Material incentives, doubly rationed by poverty and policy, were spent on subsidies – a condicio sine qua non of public health in poor rural areas. To this reviewer, adequate recognition must be given to the strategic use of social norms and the appropriation of its economies by the social planner. For example, the reliance upon pre-existing trust bonds, such as those between rural doctors and their village peers, to maximize the returns from scarce educational resources; or the recruitment of influential cured patients for campaign propaganda. Their advantage does not come from the relative cost of reputation-building vis-à-vis formal education, which might well be high, but from the fact that in most precapitalist, agrarian economies trust is abundant relative to technical information with development potential – which almost always comes from the outside. These are the sort of reflections this fine book will stimulate to readers interested in health and economic development – and the experience is strongly suggested.
