Public Health in Asia and the Pacific

Historical and Comparative Perspectives

Milton J. Lewis, Kerrie L. MacPherson, Milton J. Lewis, Kerrie L. MacPherson

• Publisher: Routledge
• Year: 2007
• Print ISBN: 9780415666497
• eBook ISBN: 9781134240555
• Edition: 1
• Topic: Storia
• Subtopic: Storia dell'Asia

The Asia-Pacific region has not only the greatest concentration of population but is, arguably, the future economic centre of the world. Epidemiological transition in the region is occurring much faster than it did in the West and many countries face the emerging problem of chronic diseases at the same time as they continue to grapple with communicable diseases.

This book explores how disease patterns and health problems in Asia and the Pacific, and collective responses to them, have been shaped over time by cultural, economic, social, demographic, environmental and political factors. With fourteen chapters, each devoted to a country in the region, the authors take a comparative and historical approach to the evolution of public health and preventive medicine, and offer a broader understanding of the links in a globalizing world between health on the one hand and culture, economy, polity and society on the other.

Public Health in Asia and the Pacific presents the importance of the non-medical context in the history of human disease, as well as the significance of disease in the larger histories of the region. It will appeal to scholars and policy makers in the fields of public health, the history of medicine, and those with a wider interest in the Asia-Pacific region.

1 Invisible borders

Hong Kong, China and the imperatives of public health

Kerrie L. MacPherson

Introduction

Hong Kong and China have experienced profound changes and developed in ways unperceived when Hong Kong was seized during the Opium War of 1841–1842 and incorporated as a crown colony (and free port) into the British empire. Territorial expansion on the Chinese mainland with the cession of Kowloon (1860), and the leasing of the New Territories (1898), subsequently created an integrated and highly urbanized area of 398.25 square miles, the majority of the population drawn from Guangdong province contiguous with the territory. The anticipated expiry of the New Territories lease (in 1997) opened negotiations between Britain and China over Hong Kong’s future. Despite Britain’s misgivings about the political, economic and developmental differences (including medical and public health standards) with China, a communist state since 1949, the Sino-British Joint Declaration (1984) returned Hong Kong to Chinese sovereignty in 1997. This was achieved partly due to China’s guarantee that Hong Kong would ‘retain its capitalist system and lifestyle’ for fifty years under the ‘one country, two systems’ concept. It was also a clear recognition by Britain of the human and geographical interdependence of Hong Kong and south China, despite the maintenance and surveillance of a political border (on both sides of the boundary) throughout the colonial period, and continuing today.

This chapter will examine the factors that influence the epidemiology and control of diseases in Hong Kong over the past century and a half and the evolution of the public health system in relationship to its human and ecological interdependence with southern China. We will examine this interdependence in matters affecting the health of the population, major disease patterns (both endemic and epidemic) and environmental factors that historically have given impetus to significant developments in public health as well as refined assessments of its shortcomings. Furthermore within this context we will explore the application of the ‘one country, two systems’ concept embodied in the Basic Law of Hong Kong. With the rise of newly emerging epidemic diseases such as H5N1 (bird flu) and more recently SARS (severe acute respiratory syndrome), both of which presented themselves in south China prior to the Hong Kong outbreaks, we will evaluate the utility of the concept in relation to the future of public health initiatives.

International transfer of modern medicine and public health

Public health as a scientific movement was introduced to China first in the treaty port enclaves and concessions opened to foreign trade and residence such as the Shanghai International Settlements and the French Concession, and in colonial outposts like Hong Kong, areas where foreigners could exert control under their treaty rights. Since these areas were overwhelming populated by Chinese it necessitated an accommodation to Chinese customs and traditional medical practices. Hong Kong’s colonial administrators, for example, guaranteed that the Chinese population, although under British rule, would be ‘governed according to the laws, customs and usages of the Chinese’ (Endicott 1964: 27). This naturally included Chinese traditional medicine (TCM) and health care. They understood that China, like other ancient cultures, had developed principles for the preservation of health (weisheng), a distinctive medical system and an impressive pharmacopoeia, a system that had widespread influence throughout Asia. However, even at its traditional best, Chinese medical theory and its quasiempirical underpinnings, free of quantitative implications, was primarily inductive and synthetic rather than causal and analytic. Medicines were individually concocted and experiences uncollated and there was little knowledge of the pathology of diseases and their impact on populations. Epidemics were recorded in Chinese local histories with some regularity, but there was little attempt to map these diseases by place, population, incidence, standardized types and effects or aetiology – a biometrical perspective that underpins the practice of preventive medicine and public health. Indeed, there was no standardized Chinese medical education system leading to professional qualifications and registration for practitioners (with the exception of various sectarian schools and the imperial college in Beijing that trained doctors for treating the imperial family), despite the production over the centuries of a body of medical literature that potentially could have fostered one. It constituted an entirely different system than the evolving science of medicine in the West (MacPherson 1987: 12–14).

This encouraged foreign medical doctors and sanitarians in Hong Kong and China to put in place their own systems for the control and abolition of deadly diseases; the need for sanitary reform of their environment and the means to ensure its effectiveness; and the nurturing of personal and professional initiatives and institutions supportive of civic or public health. Self-governance in colonial administrations such as Hong Kong or in the municipal governments formed in the treaty ports such as the Shanghai settlements was integral to the creation and implementation of public health systems, and, as had been the experience in major Western cities, urban government was preponderantly the consequence of the drive for better health. In traditional China, urban and rural administration was indistinguishable and there was no ‘municipal’ government or central selfgoverning body in the cities required to register its needs, oversee its activities, or obliged to respond to the effects of rapid change communally and plan for the future (MacPherson 1987: vii–ix). By the 1890s and the first decade of the twentieth century, Chinese reformers and modernizers were vigorously discussing prospects for establishing their own municipal governments based on Western models and were quick to grasp the importance of the connection between selfgovernance and public health. Indeed it was in Guangzhou (Canton), the capital of Guangdong province that the first Chinese municipal government was founded in 1921 (Keith 1922: 101; Rogaski 2000: 30–46; Sun 1919: 1–17).

Public health in Hong Kong, 1842–1941

The assumption that underlay the British acquisition of Hong Kong in 1841–1842 was that it would serve as an entrepôt and naval and military station between the vast markets of India and China. The colony’s subsequent growth as a free port and in matters affecting the health of the community was dependent on several factors: the interconnectedness of the population with the Pearl River delta, political and economic conditions in China which became increasingly unstable throughout the century and Sino-British relations. The Chinese population of approximately 7,450 in 1841 grew to 22,860 (excluding 957 Europeans and Indians) in 1847, and increased to 280,564 (excluding 20,096 non-Chinese) by the end of the nineteenth century. Over 70% of the population, Chinese or foreign, was predominately male and 55.9% were between the ages of 20 and 45 years, Chinese families remaining in the towns and villages of south China (Hong Kong Government Gazette 11 June 1898: 532).

High mortality from fevers (malaria) and dysentery amongst the military and civilian populations in the early years gave the colony a reputation for unhealthiness. In 1843, a committee of public health was created after 24% of the troops and 10% of the civilian population died of fever between May and October of that year. The first law relating to public health was passed in 1844 and amended as the Good Order and Cleanliness Ordinance No. 14 of 1845, superseded in 1856 by an ordinance modelled on the principles established by the London Board of Health, adapted to local conditions (Hooper 1908: 158). A colonial surgeon and a surveyor general (responsible for sanitary matters) were appointed in 1843 but the construction of a civilian hospital would have to wait until the 1850s when the revenue was deemed ‘sufficient’ by the Home government, although the governor secured a house for that purpose in 1848 because of the ‘unhealthy state of the colony’ (Endicott 1964: 69, 85). In the interim, a seaman’s hospital was built by private subscription in 1843 (eventually taken over by the British Admiralty and reopened as the Royal Naval Hospital, eventually closing in 1941) and in 1844 a military hospital. The first charitable hospital for Chinese using Western medicine was supported by the London Medical Missionary Society of Guangzhou, opening in 1843 and closing in 1853, when they transferred their work back to China. In 1887, the Alice Memorial Hospital carried on its work by expanding to four hospitals that were merged into one in 1954 and which is still operational today.

Arguably the most important charitable and welfare institution was the TungWah Chinese hospital opened in 1872 for ‘the care and treatment of indigent sick’. It was financed by local subscription organized by leading Chinese merchants and a government grant of land and funds (Lethbridge 1971: 147). The Tung Wah expanded its services in clinics and dispensaries as well as establishing a hospital in Kowloon (Kwong Wah, opened in 1911) and eastern Hong Kong Island (Tung Wah Eastern Hospital, opened in 1929). All three hospitals were amalgamated in 1931 as the Tung Wah Group of Hospitals (Hong Kong Museum of Medical Sciences Society 2006: 91–99). The Tung Wah, whose directors functioned as an unofficial channel of communication and advisory body to Chinese officials on the mainland, offered exclusively traditional Chinese medical treatment. Although Western medical doctors may have grasped the principles of TCM, they discounted its effectiveness and eschewed it in their practice. But non-interference with Chinese practices seemed prudent since the colony and south China benefited from the Tung Wah’s travelling smallpox vaccinators. Governor Hennessy noted with some satisfaction that the ‘amount of professional life amongst the Chinese’ could be seen by the increase of traditional Chinese doctors from 198 in 1876 to 333 in 1881, and herbalists from 164 to 243 (Hennessy 1881: 3).

However, the two systems came into conflict over the control and treatment of bubonic plague introduced into the colony from Guangzhou – a city that was initially compared favourably with Hong Kong by medical missionaries in the 1880s (Kerr 1888: 134–138). Although neither medical system could ‘cure’ the disease until the pathogen was identified, its aetiology investigated and a vaccine had been produced, methods of control did affect its prevalence. Western medical understanding of contagions (from the 1870s to 1890s many of the causal agents of important contagious diseases had been identified) dictated a very different course of action than those practiced by TCM practitioners. In the aftermath of the 1896 epidemic, an official inquiry recommended that a Chinese doctor trained in Western medicine be appointed to the Tung Wah hospital and treatment, whether Chinese or Western, be provided on a voluntary basis (Whitehead 1896: 18).

Fortuitously, finding qualified candidates was possible as the Hong Kong College of Medicine for Chinese, founded in 1887 (Dr Patrick Manson, the ‘father of tropical medicine’, was the first dean), had graduated its first two students in 1892, including Sun Yat-sen who would become the ‘father of the Chinese revolution’. In 1912, the college became the medical faculty of the newly opened University of Hong Kong and in the following year its medical degrees were fully recognized by the United Kingdom General Medical Council. Yet a dual system of medicine was countenanced; Chinese medicine and traditional practitioners however were basically unregulated (Western-trained medical practitioners were first registered in 1884) and the acceptance of Western (scientific) medical and sanitary practices faced keen competition, thereby complicating the ability of colonial administrators or medical practitioners to deal effectively with the rise of contagious and epidemic diseases due to the rapid influx of mainland Chinese and exacerbated by poverty and overcrowding.

Demographics and public health

The demographic character of Hong Kong’s foreign and Chinese population, and its role as a major port of call for merchant shipping, foreign troops and navies, attracted large numbers of prostitutes from south China. This affected the incidence of venereal diseases; the British admiralty attributing 50% of all sickness of the force to enthetic diseases. In 1857, the colonial government passed Ordinance 12 of 1857 for checking the spread of venereal diseases. The scheme of control entailed the licensing of brothels and restricting them to certain portions of the town, as well as enforcing the medical inspection of prostitutes and their detention in Lock hospital until ‘cured’. The brothels were taxed to support medical treatment. Keepers of licensed boarding houses for seamen were responsible for reporting sickness among the men and seamen could be fined or imprisoned for not complying with the regulations. In 1867, the Hong Kong government was instructed by London to replace this with the Contagious Diseases Ordinance modelled on the British law. Whether the ordinance had any significant effect on the spread of these diseases is difficult to ascertain from the reported statistics, although the Inspector General of Her Majesty’s Naval Hospital declared that venereal diseases had ‘all but disappeared from the colony’ (Medical Times and Gazette 24 June 1871: 717). Opposition to the acts in England due to the compulsory powers of the state led to their repeal in 1886 and in Hong Kong three years later, although Hong Kong continued to license brothels and provide medical examinations for prostitutes. Brothels exclusively for Chinese continued to be exempt from medical inspection (MacPherson 1997: 85–112; Miners 1988: 191–199).

The male predominance in the population began slowly to diminish and an increase in ‘family life’ was noted in the early twentieth century, partly attributed to the sanitary reforms undertaken in the preceding decades, although epidemics of smallpox (1887–1888), cholera (1890) and plague (first notified in 1894) continued to take their toll along with fevers, malaria, dysentery, typhus and so on. Statistics, such as they were, also revealed the crude death rate among Chinese of 24.18 per 1,000 (underestimated) and 18.2 for non-Chinese which, the registrar general opined in 1891, compared favourably with the annual death rate in England and Wales of 26.2 per 1,000 (Registrar General 1892: 233). Yet the registrar general also knew that Chinese deaths went unrecorded and bodies were shipped back to China for burial (a service provide by the Tung Wah) and many of the seriously ill returned to their home villages to expire, evasions purportedly obviate Ordinance No. 7 of 1872, copied from British law and requiring the registration of births and deaths. The birth rate also exposed serious issues of under-reporting, particularly of female births which were usually one-third less than male births. The Chinese infant mortality rate (below five years of age) accounted for nearly half of the number of total deaths registered in the general population (Registrar General 1894: 148).

Provisions were made for the registration of persons in 1844, and for purposes of ensuring the health and safety of ships carrying Chinese in 1856, but immigration into the colony was basically unrestricted (Registrations of Persons No. 18 of 1844; Chinese Passengers Act of 1855). The annual movement across the border – arrivals and departures – ranged from 73,767 arrivals and 51,247 departures in 1884 to a high of 1,436,710 arrivals and 1,425,897 departures in 1924 (Medical and Sanitary Reports 1924: 38). Furthermore, the colony functioned as a transhipment point for Chinese emigration, not only to the Straits Settlements but also many places throughout the world. Some attempt was made at medical inspection in 1867, specifically for ‘securing the Health of Emigrants . . . clearing through Hong Kong’ (Ordinance No. 6 of 1867). Diseases, endemic or epidemic, could be imported or exported as readily as opium or tea and had an impact on disease patterns in the region. Rapid migration into and out of the colony accompanied major disturbances on the mainland, a pattern that would continue throughout the colonial period, straining resources and creating serious conditions of overcrowding in the urban areas.

Sanitary reform

Official cognizance of the insanitary state of the colony in the 1870s and threats to the general health of the community from deaths due to ‘filth poison’ can be attributed to several vectors: the governor’s enlightenment over the contamination of his water supply at his residence on the Peak due to the dumping of rubbish and night soil on the slopes overhanging the reservoir; the annual reports of the colonial surgeon condemning housing, drainage, water supplies and sanitation; and ‘constant representations’ by the officer in command of the troops to the secretary of state for the colonies as to the insalubrious condition of the town and the affects on the health of his men (Colonial Surgeon 1879: 1–45). The upshot was an invitation to Osbert Chadwick C.M.G., a former royal engineer and son of the great British sanitarian Sir Edwin Chadwick, to visit Hong Kong and report on the sanitary conditions of the city and to recommend a course of reform which was submitted to the government in 1882. Chadwick was also invited to Guangzhou, the provincial capital of Guangdong province, to advise on water supplies, no doubt reflecting the interest in these developments in the Shanghai International Settlements which opened the first modern waterworks in Asia in 1883 after a ten-year struggle to map out the medical topography and sanitary reforms requisite to the growth and prosperity of the port (MacPherson 1987: 83–122). The Chadwick report was a tour de force and laid bare deficiencies in drainage, water supply, sanitation, particularly defective housing construction and design, all of which were compounded by overcrowding in the urban areas. Extensive recommendations were made affecting all aspects of environmental hygiene, town planning and public works by creating a partially elected Sanitary Board in 1883 (replaced by the Urban Council in 1935) as well as the reorganization of the medical department (Chadwick 1882: 1–15).

Implementation of the proposed Public Health Ordinance was stalled due to controversy over the clauses requiring landlords (the majority of whom were Chinese) to provide open spaces in the rear of their properties thereby diminishing their rental income, clauses that were deleted before the passage of the ordinance in 1887. Dr Kai Ho Kai (later Sir Kai), a Hong Kong-born, British-trained medical doctor and barrister who served on the Legislative Council, the Sanitary Board as well as founding the Alice Memorial Hospital (named after his deceased wife), led the opposition unexpectedly on the basis that Chinese should not be treated like Europeans and forced to comply with sanitary measures or ‘improvements’ they did not want (Choa 1981: 71–90); surprisingly too, since sanitary reform in Shanghai and proposals for a pure water supply in Guangzhou were generally known (MacPherson 1987: 68–82; Sun 1957: 1020–1023). Although the ordinance based on Chadwick’s report was the most important piece of public health legislation in the colony, in pra...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Illustrations
• Contributors
• Public health in Asia and the Pacific
• 1 Invisible borders
• 2 History of public health in modern Japan
• 3 A history of public health in Korea
• 4 History of public health in modern India
• 5 Public health in Thailand
• 6 ‘Could confinement be humanised’?
• 7 Conflict and collaboration in public health
• 8 The political determinants of public health in Timor-Leste
• 9 From colonial economy to social equity
• 10 From colony to global city
• 11 Public health and the clash of cultures
• 12 Public health in Australia from the nineteenth to the twenty-first century
• 13 Papua New Guinea
• 14 History of public health in Pacific Island countries