Tuberculosis – The Singapore Experience, 1867–2018

Disease, Society and the State

Kah Seng Loh, Li Yang Hsu

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9780367354534
• eBook ISBN: 9781000762495
• Topic: Politica e relazioni internazionali
• Subtopic: Governo americano

Through a rich account of tuberculosis in Singapore from the mid-nineteenth century to the present day, this book charts the relationship between disease, society and the state, outlining the struggles of colonial and post-colonial governments to cope with widespread disease and to establish effective public health programmes and institutions. Beginning in the nineteenth century when British colonial administrators viewed tuberculosis as a racial problem linked to the poverty, housing and insanitary habits of the Chinese working class, the book goes on to examine the ambitious medical and urban improvement initiatives of the returning British colonial government after the Second World War. It then considers the continuation and growth of these schemes in the post-colonial period and explores the most recent developments which include combating the resurgence of TB and the rise of antimicrobial resistance.

1 The pauper hospital

The long-documented history of tuberculosis in Singapore began only some 50 years after Stamford Raffles first founded a factory on the island in 1819. This was after the colony of the Straits Settlements, comprising Singapore, Penang and Malacca, was transferred from the British colonial government in India to the Colonial Office in London in 1867. The transfer established a direct line of command between the metropole and the colony, laying the basis for a more active policy towards sickness and health. More broadly, this change was part of the expansion of modern medical administration throughout the British empire in the second half of the century.¹ Nevertheless, the Colonial Office, like its predecessors in Singapore, soon deemed tuberculosis to be of secondary concern.

It is difficult to write the history of tuberculosis in Singapore in the second half of the nineteenth century. It was a serious disease connected, on the one hand, to immigration and an economic system predicated on free trade, and on the other to the endeavours and struggles of the emergent colonial state. This largely limited tuberculosis to being written from the vantage point of the colonial official and hospital. The post-transfer British administration was more concerned about other diseases. The pages of the Health Department reports were filled with deliberations over dreaded notifiable epidemic diseases such as cholera (outbreaks of which frequently struck the town area, including the hospitals), bubonic plague (leading the government to institute quarantine measures for immigrants) and smallpox (which precipitated a not-too-successful vaccination programme in 1869). The official gaze on non-epidemic illnesses fell on beri beri (a leading killer thought then to be contagious), leprosy and mental illness (both of which provoked social horror and caused sufferers to be kept away from the public in colonial asylums), and the venereal diseases (the focus of which targeted prostitutes under the Contagious Diseases Ordinance).²

It was not that tuberculosis was unknown to colonial officials and doctors in late nineteenth-century Singapore, as it was categorised under a group of ‘constitutional diseases’ or ‘fevers’. But while there were fairly periodic, and occasionally substantial, statistics and commentary on other diseases, information on tuberculosis was surprisingly fragmentary, irregular and incomplete. No policy as such existed for the disease. Following the documentary trail of this elusive killing affliction was frustrating: for instance, the yearly medical reports of Tan Tock Seng Hospital (TTSH), the pauper hospital of nineteenth-century Singapore, contributed in large part to the narrative recounted here, but the history of the hospital does not adequately cover that of the illness. It was also difficult to map trends over time as the chroniclers of health and disease in colonial Singapore changed their minds over the diseases to document and highlight – seemingly arbitrarily.

All these reflect the limited interest of Singapore’s officials and physicians in tuberculosis up to the end of the nineteenth century. This was indicative of a constrained approach to medical governance, which focused on immediate or manifest threats such as the notifiable epidemic diseases, or illnesses that provoked social anger. Nevertheless, despite the paucity of sources, it was still possible to pin down tuberculosis to some extent and write about it as a historical subject. There was some early official interest in the illness, which grew and was eventually transformed by the emergence of sanitary science at the end of the nineteenth century. The keys to understanding tuberculosis in this early period were the paupers who comprised the bulk of the sufferers of the disease, and the hospital where they arrived (and often died), or which they tried to avoid – TTSH. The paupers and pauper hospital provide a rare glimpse into the underside of an otherwise thriving, globally connected colonial entrepôt which was open to trade, immigrants and sickness. The historical insights are still relevant to contemporary Singapore.

The pauper problem

Until after the transfer of the Straits Settlements, most tuberculosis patients in the colonial record were not paupers, but patients of the General Hospital (GH) who were admitted on account of their illness. GH is usually accepted as Singapore’s first modern hospital, built in 1821 and sited in the nineteenth century at various parts of the town area such as Bras Basah Road, Pearl’s Hill, Kandang Kerbau, and Sepoy Lines. However, it was originally intended as a hospital for European seamen and employees of the colonial service, both European and Asian. It was from these two groups that GH’s tuberculosis patients were drawn, the number of which was very small up to 1870, usually less than ten cases yearly.³ In the 1850s, local English-language newspapers carried advertisements for ‘coughing lozenges’ and herbal preparations as remedies for pulmonary tuberculosis, targeted at European and educated Asian consumers.⁴ Besides GH, tuberculosis also occurred among the patients and inmates of other institutions in Singapore such as the mental asylum. In 1864, it was also cited among the prevalent diseases at the hospital for convict workers who had been brought from India to carry out public works.⁵

The disease treated at GH was largely transnational, and deadly. In 1873, six out of eight Europeans admitted for pulmonary tuberculosis at the hospital died; among them were Spanish sailors en route to Manila. Their length of treatment lasted ‘barely four days’, ‘having been sent to Hospital from different ships almost in a dying state’, while the ‘exertion consequent upon their removal to Hospital hastened their death’.⁶ The number of Asian tuberculosis patients at the hospital was small (only two), but the mortality rate was 100 per cent (both patients died). At GH that year, ‘The greatest mortality occurs under the head of Phthisis’, but the six deaths there were too small for the total of Asian tuberculosis sufferers in Singapore.⁷

In contrast, the bulk of Singapore’s population who had tuberculosis represented a much larger and very different group and social class: namely, the paupers. Historically, paupers are interesting: in nineteenth-century England, for instance, pauperism came to the state’s notice as a serious problem of work-shy and idle people which was infecting and demoralising the labouring class as a whole. It began to attack the broad charity which hitherto had been given freely to paupers, by distinguishing between those deserving of relief and others who were not. Part of the impulse was punitive: able-bodied paupers were sent to the workhouse under the provisions of the Poor Law as punishment for their idleness, and strenuous efforts were made to screen out ‘clever paupers’ who were trying to obtain unmerited charity.⁸ As a former vagrant in Britain reflected, the twentieth-century establishment still regarded vagrants and paupers as a group of the ‘socially sick’, whom it found embarrassing and wanted to integrate into capitalist society.⁹ The imposed solutions to pauperism were thus thrift and regular hard work. On the other hand, deserving paupers would receive humanitarian relief. They included infirm, decrepit or ill persons who were physically unable to work and provide for themselves, who would be sent to hospitals to be cared for.

Singapore had paupers since its founding, and most of them were sickly. In fact, they were closely tied to its early history. The British government, educated Europeans and Asian community leaders were aware of them and perceived them to be a social issue. As the port of Singapore grew, so ill paupers begging and in many cases dying in the streets became a common sight. Given the lack of effective control over the coastlines of what was an open free port, Singapore’s beaches were a convenient dumping ground for the unwanted ‘social rejects’ of the neighbouring Dutch East Indies and Malay states throughout the nineteenth century. A letter to a local newspaper in 1830 lamented:

As if we had not a sufficient supply of such living corruption continually imported from various parts of China in junks, we are complemented with all those who find their way to Sambas and Pontiana, who are landed at Palembang and Banca, of which place, Rhio [all places in the Dutch East Indies], is the grand depot. All of them are collected by our kind neighbour and during the night put on shore to the eastward of this island in droves of 20 and 30, who in course of time drag their filthy carcasses to Town, bringing in their train dire diseases with all the commitments of a leper house.¹⁰

As the letter intimated, many of the paupers had been discarded in Singapore because they were decrepit or ill. Some suffered from leprosy and mental illness – diseases with visible symptoms that provoked public horror or pity. The British discovered most of them to be recently arrived immigrants who spoke in unintelligible tongues, likely Chinese. As the paupers appeared in the streets and other public places – without abode, penniless, seeking alms, and often seriously sick – the authorities deemed them to be illegal vagrants and had them summarily rounded up by police.

The question of what to do with these seized paupers preoccupied the government and educated public. In contemporary British thinking, most of them were deserving of relief. Their diseases and general poor constitution meant that a hospital of sorts would be the answer, but this would not be a hospital in the modern sense of the word, as the 1830 letter made clear:

there can surely be but one opinion, i.e. that the Chinese and they only be compelled to provide a proper asylum and support for their suffering countrymen.¹¹

Thus, the institution for the abandoned paupers was not only a hospital in terms of the therapy it provided, but also a sanctuary, lock-up and death house combined. Such a hospital was meant to keep the paupers from returning to the street – and thus from the public – as much as it was to offer them relief. Just as importantly, as the letter proposed, the hospital would be funded by the Chinese community, rather than the colonial administration. Efforts to deal with the paupers throughout the nineteenth century stem from these two perspectives.

The reference to leprosy in the letter is telling, for the paupers were in equal measure pitied and feared for their diseases. As late as the 1890s, many of the admissions to the Pulau Jerejak leprosarium to the north of Singapore were Chinese who did not speak a word of Malay, having been dropped there from Java, Sumatra or directly from China.¹² Another disease similar to leprosy, also invoking public disgust and social stigma, was mental illness. The sufferers of both diseases were largely paupers. In 1893, the medical superintendent of the mental asylum protested about the island being used as a ‘dumping ground of the maimed, the halt, and the blind of our neighbours’.¹³ The treatment of these mental sufferers was also deemed less important than their removal from the public eye by police, thereafter which they were held in the convict gaol.¹⁴

In addition to leprosy and mental illnes...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• List of abbreviations
• Introduction
• 1 The pauper hospital
• 2 Disease of town-dwelling Chinese
• 3 Houses and races of the colony
• 4 Struggle for a post-war policy
• 5 The Tuberculosis Control Unit
• 6 The action programme
• 7 Laboratory of citizenship
• 8 Newborns and children of the nation
• 9 SATA: The community against TB
• Conclusion
• Bibliography
• Index