Reforming Public Health in Occupied Japan, 1945-52

Alien Prescriptions?

Christopher Aldous, Akihito Suzuki

• Publisher: Routledge
• Year: 2011
• ISBN:
  9781136498800
• Edition: 1
• Topic: History
• Subtopic: Japanese History
• Index: History

Whilst most facets of the Occupation of Japan have attracted much scholarly debate in recent decades, this is not the case with reforms relating to public health. The few studies of this subject largely follow the celebratory account of US-inspired advances, strongly associated with Crawford Sams, the key figure in the Occupation charged with carrying them out. This book tests the validity of this dominant narrative, interrogating its chief claims, exploring the influences acting on it, and critically examining the reform's broader significance for the Occupation and its legacies for both Japan and the US. The book argues that rather than presiding over a revolution in public health, the Public Health and Welfare Section, headed by Sams, recommended methods of epidemic disease control and prevention that were already established in Japan and were not the innovations that they were often claimed to be. Where high incidence of such endemic diseases as dysentery and tuberculosis reflected serious socio-economic problems or deficiencies in sanitary infrastructure, little was done in practice to tackle the fundamental problems of poor water quality, the continued use of night soil as fertilizer and pervasive malnutrition. Improvements in these areas followed the trajectory of recovery, growth and rising prosperity in the 1950s and 1960s.

This book will be important reading for anyone studying Japanese History, the History of Medicine, Public Health in Asia and Asian Social Policy.

1 Confronting epidemics

One of the most insistent claims made by the Occupation's Public Health and Welfare Section (PH&W) related to its instrumental role in modernizing and democratizing Japan's system of public health. And yet those who looked beyond the wreckage of defeat and the health crises that came in its wake and explored the evolution of public health in Japan since the Meiji period (1868–1912) would have been struck by the strong emphasis on the ‘modern’ and ‘scientific’, terms inevitably defined according to Western criteria, that animated hygiene and social improvement campaigns from the late nineteenth century onwards. Indeed, there are striking parallels in practical terms between the reforming ambitions of Sams and his staff and the endeavours of such key figures as Nagayo Sensai, Gotō Shinpei, Mori Ōgai and Kitasato Shibasaburō during the Meiji period (1868–1912). The two groups were united in their determination to strengthen immunity to disease by means of vaccination, prevent the incursion of alien infections by strict quarantine regulations, reduce rates of morbidity by cleaning up local environments, and protect the health of Japanese through better nutrition.

Both groups of reformers embraced science and technology as the core components of a modern public health system, the essential difference between them best described as an ideological one: whereas the starting point for Nagayo and his contemporaries, born of the immediate challenges that Japan faced, tended to be nation building, a predominantly statist perspective, the declared point of departure for Sams was the health of the individual, the essential social foundation for a robust democracy. Sams contrasted this American paradigm of public health with the ‘German model’ of state hygiene that had held sway in Japan since the late nineteenth century and that had largely failed, he argued, to safeguard the health of the Japanese people. Indeed, Sams complained in February 1946 of Japanese ineptitude in relation to the control of communicable diseases, blaming it on ‘a blind following of the theories and system of Germany’.¹

This chapter critically examines this claim. It explores the origins and defining principles of Japan's public health system from the late Tokugawa period (1600–1868) through to 1931, when Japanese aggression in Manchuria heralded the beginning of what some historians call the ‘fifteen-year war’. It first examines the architects of modern hygiene in Japan, and their keen appreciation of developments throughout Europe, particularly in Britain and Germany. Interestingly, the origins of Japanese public health coincided with the lively, sometimes acrimonious, debate over the ‘germ theory’ of disease – the attribution of diseases to particular bacteria – and the bacteriological triumphs of its chief advocate, Robert Koch, with whom Kitasato came to have a close professional relationship. This was one of a number of partnerships that demonstrated Japanese engagement with international developments in public health, the implications and ramifications of which seem to have captured the attention of Japanese scientists as much as those of other nations.

Following this book's predominant approach, the chapter then focuses on key diseases, most notably smallpox (a disease with a long history in Japan) and cholera and plague (both apparently alien infections), and the origins and efficacy of measures taken at both national and local levels to prevent or check them. Judgements about the degree to which the Meiji and Taisho (1912–26) authorities succeeded in building and maintaining a modern public health infrastructure can best be made with reference to rates of disease morbidity and mortality. These data sets shed some light on the seriousness with which the Japanese government sought to identify and monitor health problems. The focus here is on acute infectious diseases, cases of which had to be swiftly reported and dealt with due to their potential for generating epidemics. It seems that the challenge represented by some of these diseases, most notably dysentery, typhoid and diphtheria, was greater than that posed by smallpox, cholera, plague and typhus. The latter were apparently more susceptible to public health interventions that included immunization, quarantine, isolation and disinfection. Of course, the methods of control adopted by the authorities is just one vantage point from which the rising, steady or declining profile of a disease can be viewed – others include the behaviour of society at large and the virulence of the disease itself, which may decline due to subtle changes in its ecology. The chapter concludes with a brief appraisal of the impact of the influenza pandemic of 1918–19 on Japan, a useful gauge by which to measure the efficacy of public health systems and organizations set up to meet the challenge of a major epidemic.

Learning from Europe

By the time Japan was ‘forced open’ by Commodore Perry in 1853, there was already much interest and some expertise among Japanese in Western medicine. This was due to the Dutch trading post on the island of Dejima at Nagasaki, representing a single, narrow window on the Western world from 1641. Here, contact with a number of European doctors, most notably Germans, fostered a private network of ranpō – Japanese doctors who gravitated towards the ‘Dutch style’ of medicine, regarding it as superior to the traditional Japanese approaches of kanpō, deriving originally from China. Several studies of this period have illuminated the advances in medical understanding, particularly anatomy, made by such Japanese pioneers as Sugita Genpaku (1733–1817) and Ogata Kōan (1810–63). Ogata founded the famous Teki juku, which trained Japan's future ‘father of public health’, Nagayo Sensai, in the 1850s.

Alongside such Japanese students of Dutch learning (rangaku) stand a number of dedicated German doctors, most notably Philipp von Siebold, who resided in Japan twice – during 1823–29 and 1859–61 – and whose energy and commitment to promoting medical science in Japan did much to recommend German medicine to Japanese advocates of modernization. What concerns us here, however, is not the decline and eclipse of kanpō by Western, scientific medicine, nor the Meiji government's apparent preference for research-focused German medicine over the clinical education-based British model.² Rather, it is the emergence of public health as a central governmental concern and a strategic priority. In the face of devastating cholera epidemics, the Meiji oligarchy saw it as fundamental to the process of fukoku kyōhei(enrich the country, strengthen the military).

The history of public health in Japan really begins in 1872, with Nagayo Sensai's participation in the Iwakura Mission (1871–73), his original brief being medical education. The chief purpose of this mission was revision of the ‘unequal treaties’ imposed on Japan by Western nations in 1858. However, largely due to failure in that regard, it is remembered more as a wide-ranging exercise in learning from the West. A trip to London provided an opportunity to consider the outlines of a national structure of sanitary districts and health officers, in advance of the third Public Health Act of 1875.³ Nevertheless, it was in Berlin that Nagayo's interest decisively shifted away from medical education to something much broader and more significant in terms of the Meiji project of nation building. Hugely impressed by the research laboratories he visited in Berlin and inspired by the political importance of German medical experts, Nagayo began to broaden his horizons. He started to grapple with problems and issues that transcended those of medical education and practice, demonstrating a rising awareness of the young discipline of public hygiene or sanitary science. Later, Nagayo recalled his realization of the crucial role of the state as guardian of the people's health:

I heard the words ‘sanitary’ and ‘health’ everywhere and, in Berlin, ‘Gesundheitpflege’. . . . Eventually I came to understand that these words meant not only protection of the citizens’ health, but referred to the entire administrative system that was being organized to safeguard citizens’ health.

He identified the chief features of a sophisticated administrative order that encompassed sanitary engineering. This included the provision of clean water and the effective disposal of human waste, the dissemination of information about hygiene among the public by local governments, the policing of hygiene regulations and the careful recording of morbidity and mortality rates for infectious diseases, together with those of vaccination. According to Ann Jannetta, ‘This vision of a way to build a healthy and strong Japan through the offices of the state appealed to him enormously. He could see an entirely new field of operations in which he could play a formative role.’⁴

Before he could set about playing that decisive role, however, he had to define it. The fundamental problem for Nagayo at the outset was how to capture the meaning of an enterprise which was largely alien to Japanese experience, and for which there was no recognized terminology. In her fascinating study of ‘hygienic modernity’, Ruth Rogaski explores the rather roundabout route by which Nagayo sought to encapsulate the novelty and import of what he had encountered in Europe. Rejecting ‘plain’ terms like kenkō or hoken (meaning ‘health’), Nagayo chose the term eisei from a Chinese Daoist classic. He was swayed by the elegance of the characters and their apparent suitability for the grand undertaking he was describing.⁵ Ironically, the term eisei already had some currency in Japan but described an individual's regimen rather than a collective enterprise.⁶ Indeed, Nagayo found it necessary to caution Japanese in 1883 that eisei was essentially a public endeavour (as captured by the phrase kōshū eisei or ‘public hygiene’), and that it should be understood in terms of ‘social benefits rather than . . . individual pleasures’.⁷ As William Johnston puts it, ‘Nagayo used eisei to connote community health policed with state authority, but in common usage eisei was synonymous with “nurturing life” (yōjō)’, attributing this discrepancy to his ‘near absolute faith in the powers of the state’.⁸

This sense of an overwhelmingly top-down approach to improving the public's health for the sake of the nation caused Kajiwara Saburō of Osaka University to characterize Japanese hygiene before the Second World War as ‘a hygiene of authority (the government), a non-democratic hygiene’.⁹ This was in contrast to the situation in Europe, particularly Britain, where there was a real tension between local autonomy and central control and where civic engagement lay at the heart of public health reform. Indeed, Susan Burns argues that ‘even in the German states . . . the nineteenth century saw the rise of civil reformers, many of them physicians, who worked to take power over medical matters away from government bureaucrats’. In stark contrast, the emergence of public hygiene in Japan ‘predated industrialization and its attendant health problems and . . . emanated not from civil society but from the new central government’.¹⁰

Hence Johnston contends that Nagayo found the term eisei particularly appealing, because it could readily be translated as ‘police’ (ei) ‘life’ (sei), so drawing on ideas that he had encountered in Germany relating to the concept of ‘medical police’. This envisaged an extensive system of public regulation of people's lives ‘from the womb to tomb’, defined in Professor Johann Peter Frank's multi-volume System of Complete Medical Police, published during the period 1779–1817. According to Rosen

the exposition serves not so much for the instruction of the people, or even of physicians, as for the guidance of the officials who are supposed to regulate and supervise for the benefit of society all the spheres of human activity, even those most personal.¹¹

At the heart of this new ideology was the conviction that a large and healthy population was the sine qua non of a powerful state. For Johnston, this conviction impelled the architects of modern hygiene in Japan: ‘Medical police maintained public health not because individuals had the right to a healthy life but for the good of the state.’¹²

However, there is some debate among historians concerning Nagayo's preferred model of public health. Kasahara Hidehiko argues, for example, that he was keen to promote an ‘autonomous’ hygiene policy (jichi eisei) along British lines.¹³ Of course, there was no sense at this time of a stark division between a German centralized model of state intervention and a British localized one of community engagement, a dichotomy that has perhaps been overdrawn in the historiography of this subject.¹⁴ Indeed, Rogaski contends that ‘Nagayo's vision for eisei hoped to combine the best of the British and German systems. It was not only laboratories and quarantines: It also included education, welfare, and popular participation.’¹⁵ This was made clear when Nagayo underlined the importance of local initiative in public hygiene in an address to the Great Japan Private Hygiene Society (Dai Nihon Shiritsu Eiseikai) in 1888, praising Britain's achievements in this respect, and noting that they had influenced developments in Germany from the 1870s.¹⁶ Lee pushes this argument even further, arguing against the historical grain that ‘the Meiji government considered the British administrative system of public hygiene to be most suitable for enhancing Japan's national strength’.¹⁷ However, its fragmented nature surely ran counter to the Meiji oligarchy's determination to control policy and administration from the centre. Perhaps more persuasively, Marui Eiji maintains that ‘Japanese “eisei” had never been a progeny of Edwin Chadwick, but one of the most honest children of Pettenkofer or Grotjahn’, and that ‘human-oriented activity in the community was apt to be neglected . . .’.¹⁸ As will become clear from the next section, Nagayo's philosophy of jichi eisei gave way to one of police control, an approach apparently favoured in particular by Gotō Shinpei.

Hygiene police, hygiene associations and military hygiene

Perhaps the best way to test some of these assertions is to trace the development, both at the centre and in the localities, of an administrative and regulatory framework for public hygiene. On his return from Europe, Nagayo took charge in June 1873 of the new Bureau of Medical Affairs (Imu Kyoku), located within the Education Ministry, and set about designing a nation-wide system of public hygiene, presenting his ideas in a 76-article ‘medical policy’ (Isei). In addition to urging the licensing of doctors, midwives and pharmacists, the establishment of medical schools and public hospitals, and the control of pharmaceutical products, this foundational document called for the establishment of a Bureau of Hygiene. This would serve as the core of a network of seven public health districts, each equipped with an organization charged with ensuring that local authorities acted on the central government's hygiene directives.¹⁹

Effective policies of public health, particularly for a country unfamiliar with its precepts, necessitated central control and coordination. Thus, the new Bureau of Hygiene (Eisei Kyoku), which supplanted the Bureau of Medical Affairs, was transferred in 1875 to the Ministry of Home Affairs (Naimushō), the key engine of administrative centralization and enforcement. Nagayo headed this bureau from its inception until 1891, working above all to combat epidemics by means of quarantine, vaccination and improved sanitation.²⁰ In 1876, for example, the bureau issued Regulations for Smallpox Prevention, which specified a schedule of vaccination from birth, and sent instructions to prefectural authorities in 1879 to increase rates of vaccination among the public. The following year the Regulations for the Prevention of Infectious Diseases outlined strategies for the prevention of cholera, typhoid, dysentery, diphtheria, epidemic typhus and smallpox, together responsible for 150,771 (16 per cent) of the total deaths in 1886.²¹ Monitoring these developments closely was the Central Sanitary Board (Chūō Eiseikai), a body that rapidly grew in importance as the challenges of public hygiene mounted.

Establishe...