Smoking among Doctors: Governmentality, Embodiment, and the Diversion of Blame in Contemporary China

Abstract

How and to what effect have physicians in China become frequent cigarette smokers and blamed as engines of nationwide tobacco-induced suffering? Building on governmentality heuristics, I argue that multilevel interactions of biopolitics and male embodiment have been especially significant in shaping these phenomena. Of the effects gleaned in my fieldwork ongoing since 2003, the most important is a deflection of responsibility for tobacco-induced death away from incoherent leadership decisions—some aimed at protecting Chinese citizens from tobacco, others at facilitating trillions of cigarettes being sold annually in the PRC—made over recent years in and outside the country.

Key Words:

• China
• cigarettes
• doctors
• embodiment
• governmentality
• masculinity

ACKNOWLEDGEMENTS

Research for this article was supported by NIH grant K07CA093605.

Notes

See “China to Start WTO-Related Tariff Concessions for 2002” (Newsedge 2001); see also Zhong and Yano (2007).

Seventy percent of China's tobacco is now grown in its midwest and southwest provinces, where it has been responsible for 40 to 80 percent of overall government revenue in the past decade (Wang 2006:141–142).

Even with the smuggling of cigarettes into China, Chinese companies enjoy domestic market shares of as much as 94 percent (Lee and Collin 2006:1081).

Merriam-Webster Online. http://www.m-w.com/dictionary/irony (accessed December 10, 2007).

Recent data on smoking among health professionals are not available for all countries. Among the at least 78 countries for which data are available, 30 of those countries report that at least one in four of their health professionals are regular cigarette smokers. In Buenos Aires, Argentina, 37 percent of female and 33 percent of male third-year medical students acknowledge being cigarette smokers. Rates of smoking among physicians are especially high in Central Asia and Eastern Europe; for example, more than half of all doctors in Armenia and Bulgaria smoke (Mackay et al. 2006: 26–27, 98–105).

For a recent review of data on the health risks posed by cigarette smoking, see Samet (2001).

By somatosocial I mean the experiential realm that manifests and melds—through processes of embodiment—corporeality, personhood, and forces of sociopolitics.

Worldwide, nearly 1 billion men and 250 million women are daily smokers; 35 percent of men and 22 percent of women in developed countries, and 50 percent of men and 9 percent of women in developing countries smoke; and of the 150 countries for which gender-specific data are available, in at least 34 of them, 10 times as many men smoke as women (Mackay, Eriksen, and Omar 2006:22–25; 98–105; see also Mackay and Amos 2003). In China, of those 15 years old and above, 58 percent of males smoke daily whereas less than 3 percent of women do (Chinese Association of Smoking and Health 2004:7).

That most nurses in China are female no doubt explains the low rates of smoking within that profession, as low as 2.6 percent overall in one study (Smith, Wei, and Wang 2005).

O'Brien-Butler (1919); also cited in Cochran (1980).

In China, patriarchal hegemony long dictated that the arts of healing—because they afforded practitioners title and honor—were inequitably open to and helped to demarcate men (Hymes 1987). Spearheaded by missionaries, programmatic training of female physicians began at the dawn of the 20th century, initially in biomedicine (Lu 1999). The process, once begun, moved at a painfully slow pace. For further discussion, see Yip (1995:150–151, 230).

Although some began issuing warnings about the risks of tobacco as early as the Tang period (618–907), pre-1949 Chinese medical scholars more often touted tobacco on the grounds that it possessed a variety of harmonizing and disease-deterring qualities (Dikötter et al. 2004:26–28; Ma 1985:1; Wang 1992:44; see also Hughes 2003:36–94).

Although female doctors that I have met and interviewed in Kunming's larger biomedical facilities report rarely if ever smoking or being encouraged to smoke by anyone else, some have noted that intermittently over the years they have purchased packs and cartons of cigarettes and strategically gifted them in unopened form to colleagues and supervisors. In this way, these women have tried to participate in guanxi-building through cigarette exchange without actually needing to smoke themselves.

Data on year-to-year cigarette supply during the 1950s and 1960s is thin, but known is that from 1950 to 1979, total domestic production jumped eightfold from around 80 billion cigarettes to over 651 billion, and then more than doubled again by 1993, rising to 1.668 trillion (Yuan 1995:169). Although literally translating as “tobacco coupons” (xiangyan piao), these vouchers were only for the formal acquisition of cigarettes. The highly regionalized issuance of xiangyan piao, starting in some areas as early as the late 1950s, did not mean people were precluded from buying cigarettes or loose unrolled tobacco on the open market. Instead, as informants have explained to me, the coupons were issued, often in greatest number before the most important national holidays, to guarantee that people of all income levels could have access to cigarettes. In addition, before holidays, special coupons were often issued that allowed citizens to acquire “higher” quality cigarettes that were often not available for sale.

There is some evidence that the efficacy of this discursive binary and other forces serving to inoculate female physicians from using cigarettes began to decline during the 1980s and 1990s when post-Maoist economic liberalization fueled a significant rise in cigarette consumption nationwide. For example, Li et al. (1999) documented that, in one sample taken in the central Chinese city of Wuhan, smoking rates among female physicians between 1987 and 1996 jumped from 4.8 to 12.2 percent. Their study also chronicled a growth in smoking rates among male physicians, with a rise from 51 to 61 percent.

Emphasis here is mine.

For critical reviews of the theoretical framework (“KAP”) on which the Wang et al. (2004) study is based, see Smith (1976), Ullah (2004), and Williams and Jones (2004).

Based on her research in rural China, Farquhar makes an important and related argument about the pitfalls of assuming that “individuation” among medical professionals during the post-Mao epoch will follow any stereotypical Euro-American pattern (1996:251).

“It seems to me that the analysis of governmentality,” Foucault notes, “must refer to an ethics of the subject defined by the relationship of the self to self” (2005:252).

This seems to be somewhat supported by China's 1996 National Prevalence Survey of Smoking which found that “illness” was the most frequent explanation (47 percent) given for quit attempts (Yang et al. 1997:47).

Reflecting this agonistic outlook as well as the hostilities that doctors now often face, the Ministry of Health reported in late 2005 that over 70 percent of all hospitals nationwide had been regularly experiencing patients and their families “violently beating, intimidating, and cursing” clinical staff (Beijing Morning Post 2005).

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Matthew Kohrman

Matthew Kohrman is an assistant professor at Stanford University, where he specializes in medical anthropology. His current research engages various intellectual terrains including governmentality, gender theory, political economy, critical science studies, public health, and embodiment. Recent publications of Kohrman's include “Depoliticizing Tobacco's Exceptionality: Male Sociality, Death, and Memory-Making among Chinese Cigarette Smokers”. (The China Journal) and Bodies of Difference: Experiences of Disability and Institutional Advocacy in the Making of Modern China (Univ. of California Press).