Extrême-Orient Extrême-Occident

37 | 2014 Penser les épidémies depuis la Chine, le Japon et la Corée Thinking on epidemics from , Japan, and Korea’s perspectives

Florence Bretelle-Establet et Frédéric Keck (dir.)

Édition électronique URL : http://journals.openedition.org/extremeorient/319 DOI : 10.4000/extremeorient.319 ISSN : 2108-7105

Éditeur Presses universitaires de Vincennes

Édition imprimée Date de publication : 1 septembre 2014 ISBN : 978-2-84292-411-9 ISSN : 0754-5010

Référence électronique Florence Bretelle-Establet et Frédéric Keck (dir.), Extrême-Orient Extrême-Occident, 37 | 2014, « Penser les épidémies depuis la Chine, le Japon et la Corée » [En ligne], mis en ligne le 01 septembre 2016, consulté le 24 septembre 2020. URL : http://journals.openedition.org/extremeorient/319 ; DOI : https:// doi.org/10.4000/extremeorient.319

Ce document a été généré automatiquement le 24 septembre 2020.

© PUV 1

L’épidémie véhicule bien plus que l’idée d’une surmorbidité ou d’une surmortalité ; quelle que soit la période considérée, elle est une menace pour l’ordre politique, social, économique. En étudiant les pratiques politiques, religieuses, économiques que les épidémies suscitent en Asie orientale – Chine, Japon, Corée – dans les périodes pré-moderne et moderne, en scrutant les discours qui les évoquent, tenus dans les milieux médicaux, administratifs ou religieux, ce volume apporte un éclairage sur les manières dont le phénomène épidémique est identifié, compris et combattu dans ce qui est aujourd’hui considéré comme un des principaux foyers d’épidémies.

NOTE DE LA RÉDACTION

Numéro publié avec le soutien de l’association Nippon Koten Kenkyukai 日本古典研究 会.

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SOMMAIRE

Les épidémies entre « Occident » et « Orient » Florence Bretelle-Establet et Frédéric Keck

I. Imaginaires des foyers Imagined Sources

Les épidémies en Chine à la croisée des savoirs et des imaginaires : le Grand Sud aux XVIIIe et XIXe siècles Florence Bretelle-Establet

Jean-Jacques Matignon’s Legacy on Russian Plague Research in North-East China and Inner Asia (1898-1910) Christos Lynteris

II. Épreuves de souveraineté

Measures against Epidemics during Late 18th Century Korea: Reformation or Restoration? Dongwon Shin

Epidemic Control and Wars in Republican China (1935-1955) Michael Shiyung Liu

Framing SARS and H5N1 as an Issue of National Security in Taiwan: Process, Motivations and Consequences Vincent Rollet

III. Incertitudes du collectif

The Shifting Epistemological Foundations of Cholera Control in Japan (1822-1900) William Johnston

Epidemic Cerebrospinal Meningitis during the Cultural Revolution Ka wai Fan

IV. Regards extérieurs

Quand la terre s’arrondit. L’horizon convergent des épidémies d’Orient et d’Occident Anne-Marie Moulin

Le retour des dispositifs de protection anciens dans la gestion politique des épidémies Patrice Bourdelais

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Les épidémies entre « Occident » et « Orient »

Florence Bretelle-Establet et Frédéric Keck

Nous tenons à remercier la Nippon Koten Kenkyukai, en particulier M. Charles Vacher, pour son soutien à la revue. Notre gratitude va également à Richard Kennedy pour son aide au polissage des textes écrits en anglais par des auteurs non anglophones.

1 L’histoire des épidémies est révélatrice des « peurs en Occident »2. Parmi l’ensemble des menaces diffuses qui pèsent sur l’individu, l’épidémie tranche par son caractère soudain, brutal et collectif : elle se manifeste comme une catastrophe dans la vie quotidienne. On distingue alors de la maladie chronique, qui peut fragiliser l’individu, la maladie infectieuse qui semble affecter le groupe social de l’extérieur3. Sa capacité à passer de corps en corps met au défi les conceptions établies de la société, dont elle révèle les vulnérabilités. Lorsque le mal s’empare d’un corps, nul ne sait jusqu’où il s’étendra : les barrières du village ou de la ville ne suffisent pas, les collectifs déjà en place sont débordés. Si l’émotion soulevée par l’épidémie s’apaise d’abord en désignant un coupable du mal pour l’expulser et le détruire, l’enquête vise ensuite à cerner le lieu d’où il part pour le contrôler et l’étudier. L’épidémie est alors l’occasion de cartographier les espaces et les corps qui s’y inscrivent. Aussi la séquence des grandes épidémies raconte-t-elle, pour un historien de l’environnement, les étapes de la transformation de l’Occident : guerres civiles (peste, typhus), conquête du Nouveau Monde (variole), révolution industrielle (choléra, syphilis, tuberculose)4.

2 Le savoir sur les épidémies produit par les sociétés occidentales a été décrit comme marquant le passage de la peur à la maîtrise, de la faute à la maladie, du peuple, affecté uniformément, à la population, considérée dans ses variabilités5. La révolution microbiologique du XIXe siècle a découvert sous l’ampleur des contagions collectives les régularités des relations entre les hommes et les microbes. Il n’y avait plus besoin d’invoquer les démons du lieu ou les miasmes de l’environnement, puisqu’on pouvait manipuler les bactéries puis les virus dans un laboratoire6. En expliquant l’épidémie par les cassures dans la co-évolution des hommes et des microbes, la microbiologie, à la fin du XIXe siècle, ajoutait ainsi un troisième niveau aux deux autres aspects de la réflexion épidémiologique. Alors que celle-ci décrivait jusque-là l’épidémie comme une crise de

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surmorbidité (niveau phénoménologique) ou comme une propagation démographique et économique (niveau sociologique), ce troisième niveau ontologique apparut déterminant en dernière instance et clé de la maîtrise des épidémies.

3 Au milieu du XXe siècle, des années 1950 au début des années 1980, on pouvait penser que l’arsenal thérapeutique alors disponible était capable de résoudre la question des épidémies, la découverte, à partir des années 1980, de virus très pathogènes et potentiellement pandémiques (VIH/SIDA, Syndrome respiratoire aigu sévère (SRAS), virus Ebola, H5N1) a mis un terme à cette courte période d’optimisme : « Une nouvelle maladie infectieuse fait son apparition chaque année dans le monde, selon l’Organisation mondiale de la santé (OMS). Et tous les cinq ans, l’humanité subit une crise majeure due à l’émergence ou à la réémergence d’un virus », pouvait écrire une journaliste en décembre 20127.

4 La redécouverte de la menace épidémique, à la fin du XXe siècle, a mis essentiellement l’Asie au cœur de ce diagnostic pessimiste, du fait de son écologie, de sa démographie et de son interdépendance croissante avec le reste du monde. L’Asie orientale, et plus particulièrement la Chine du Sud, fut montrée du doigt lors de l’épidémie de SRAS (2002-2003) qui, avant de se diffuser dans le reste de l’Asie jusqu’au , avec une létalité de 10 %, fut qualifiée par un journaliste de Time Asia de « syndrome chinois 8 ». La grippe pandémique, dont on rappelle souvent qu’elle a fait plus de victimes que la guerre en 1918, est décrite comme une menace permanente dont « l’épicentre » est situé dans le Sud de la Chine9 où les oiseaux et les cochons, constituant le « réservoir » pour les mutations des virus Influenza, sont abattus en cas de nouvelle épidémie et mis sous étroite surveillance en temps ordinaire10. Si « la menace épidémique nouvelle est présente dans notre quotidien d’une façon disproportionnée au regard de sa rareté statistique et du faible nombre de victimes qu’elle entraîne11 », c’est donc qu’elle révèle l’imaginaire d’une globalisation dans laquelle l’Asie joue un rôle essentiel.

5 Alors que l’Asie orientale, en particulier la Chine, et les pays d’Asie du Sud-Est constituent aujourd’hui les foyers les plus menaçants pour un monde occidental inséré dans un mouvement intense d’échange, les peurs que cette partie du monde suscite sont plus anciennes : au XVIIIe siècle déjà, la variole est soupçonnée par certains médecins européens d’être une maladie asiatique arrivée en Occident12. La peste qui éclate à Canton et à Hongkong en 1894 apparaît comme une menace majeure pour la communauté occidentale, et induit par exemple le gouvernement français à renforcer sa présence médicale en Chine du Sud pour éviter que la maladie ne se propage dans la colonie indochinoise, voire en métropole13. C’est cette même inquiétude qui conduit les puissances européennes et américaines, au travers d’un Dudgeon (The Diseases of China. Causes, Conditions, and Prevalence, Contrasted with those of Europe, 1877), d’un Maxwell ou d’un Jefferys (The Diseases of China, Including Formosa, and Korea, 1910 et 1929) pour la Chine, d’un Angier pour le Cambodge (Le Cambodge. Géographie médicale, 1901), d’un Rouffiandis pour le Laos (Géographie médicale du Moyen Laos, 1902) ou d’un Gaide pour l’Indochine, à inventorier et cartographier les maladies potentiellement épidémiques de l’Asie, alors en grande partie colonisée par les puissances européennes14. Au tournant du XXe siècle, comme aujourd’hui, l’Asie fournit également le cadre idéal pour la recherche des causes et des mécanismes de transmission et la mise au point de thérapeutiques. Les expériences menées par Alexandre Yersin sur la peste bubonique sont bien connues. Mais les investigations s’étendent bien au-delà du seul cas de la peste et sont intimement liées au contexte de colonisation. Dans cette époque de

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grande interrogation médicale, le territoire colonisé en général, et l’Asie en particulier, fournit un cadre de choix à la recherche sur les maladies infectieuses en même temps qu’un terrain d’expérience et d’expérimentation.

6 En somme, il y a une certaine continuité dans la manière dont le regard occidental appréhende la source des épidémies : l’Asie en est souvent le foyer, qu’il s’agisse de résurgence de maladies épidémiques connues comme la peste ou le choléra, au tournant du XXe siècle, ou qu’il s’agisse de maladies émergentes, comme le SRAS au début du XXIe siècle. La continuité est aussi visible dans la manière de juger l’approche qu’en font les autorités locales. Les Européens et Américains qui arrivent en Chine à la fin du XIXe siècle expriment généralement leur consternation devant l’absence de mesures gouvernementales dans la gestion des épidémies, eux qui ont vu, depuis la seconde moitié du XIXe siècle, l’essor d’un mouvement médical où la puissance publique s’est donné le droit et même le devoir d’imposer aux individus des règles d’hygiène pour le bien de la collectivité15. Aujourd’hui encore, l’épidémie de VIH/Sida, qui ralentit en Occident alors qu’elle progresse en Asie et en Afrique, suscite des discussions sur la résistance des populations et des États à suivre les traitements prescrits par les organisations internationales de santé16. Le cas de la pandémie de grippe H1N1 en 2009 montre bien la complexité des relations entre Chine et Occident dans le contrôle des épidémies : après que la directrice de l’Organisation Mondiale de la Santé, Margaret Chan, qui fut directrice de la Santé à Hong Kong entre 1994 et 2003, lança l’alerte sur un nouveau virus, les autorités chinoises, accusées d’avoir sous-estimé le danger du SRAS en 2003, furent accusées par les observateurs occidentaux d’avoir imposé des mesures de quarantaine trop fortes contre le H1N117. Il faut donc renoncer à partir d’un centre de savoir détenteur de la rationalité sur les épidémies pour voir comment celles-ci sont pensées ailleurs.

7 L’histoire des concepts relatifs aux épidémies et des réponses – politiques, religieuses, médicales – qu’elles suscitent est mieux connue pour l’Europe qu’elle ne l’est pour l’Asie orientale. Ce volume réunit sept contributions traitant d’épidémies qui frappèrent, à différentes époques, la Chine, le Japon et la Corée. Il ne se donne par pour objectif de faire une histoire des épidémies dans cette partie du monde ; en étudiant les pratiques politiques, religieuses, économiques que ces épisodes épidémiques suscitent, en scrutant les discours qui les évoquent, tenus dans les milieux médicaux, administratifs ou religieux, il entend plutôt apporter un éclairage sur les manières dont le phénomène épidémique est identifié, compris et combattu dans ce qui est aujourd’hui considéré comme un des principaux foyers d’épidémies.

Les épidémies en Chine, au Japon et en Corée : problèmes de définition

8 Mettre au jour les notions qui sous-tendent le phénomène épidémique en différentes parties de l’Asie orientale et le type de réponses qu’il suscite nécessite tout d’abord d’identifier les termes mêmes qui le traduisent. Certes cette question ne se pose pas avec la même acuité pour les différentes époques, pré-moderne et moderne, que ce volume recouvre. S’il semble y avoir un consensus sur les manières dont le phénomène épidémique est compris au XXIe siècle, notamment parce qu’il fait l’objet d’une

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réglementation internationalement reconnue, en revanche la définition des épidémies pose des difficultés plus grandes pour les périodes antérieures.

9 En Chine, de nombreux termes ont été utilisés dans l’histoire pour désigner des maladies frappant collectivement et de manière spectaculaire18. Le caractère yi (qui contient la clé de la maladie et le caractère pour « frapper », et que certains dictionnaires interprètent comme une maladie qui se répand, liuxing) semble le plus couramment utilisé en Chine, en Corée ou au Japon, dans les textes administratifs mais aussi médicaux. Comme le rappelle Marta Hanson dans son étude sur l’évolution du discours médical relatif aux épidémies en Chine, il y a, au XVIIe siècle, une intersection entre le concept « d’épidémies fébriles wenyi » et celui des « maladies chaudes wenbing », ce dernier étant, depuis le XIIe siècle, associé au sud géographique. Du milieu du XVIIe jusqu’à la fin du XIXe siècle, les concepts de « maladies chaudes » et « d’épidémies fébriles » sont donc souvent associés, parfois utilisés l’un pour l’autre, et au centre d’un nouveau discours médical sur l’épidémie : ce discours rejette notamment l’explication classique fondée sur l’idée d’une cosmologie déterminante et lie davantage le phénomène à une anomalie de l’environnement, lui-même perçu comme intrinsèquement lié à une géographie complexe du territoire, capable de produire des corporalités distinctes. En somme, le terme d’épidémie connaît une généalogie singulière en Chine, à partir du XVIIe siècle : il renvoie moins au peuple (demos) unifié par le mal qu’à l’anomalie d’un environnement avec laquelle celui-ci est désormais unifié19. Pourtant, les phénomènes rassemblés sous ce terme ne semblent pas faire l’objet d’un accord unanime. Florence Bretelle-Establet montre dans ce volume que les caractères yi, wenyi, wenbing utilisés dans les sources administratives pour signaler une maladie exceptionnelle et dont les « morts sont innombrables » (sizhe wusuan) donnent lieu à des descriptions de maladies qui, dans les sources médicales, ne sont pas toujours nécessairement liées à des phénomènes collectifs.

10 Comment les acteurs, qu’ils soient médecins, administratifs ou simples malades, identifient les épidémies est donc une question qui parcourt l’ensemble des contributions de ce volume. Parfois le phénomène épidémique est mis en relation avec une entité nosologique précise – « épidémie rouge », « effondrement en trois jours », « désorganisation soudaine » – en sorte que se pose le problème, classique pour tout historien des maladies, de parvenir à identifier dans une nomenclature biomédicale les termes anciens20. À quelle pathologie spécifique rattacher « l’épidémie rouge », décrite ici par Shin Dongwon, qui s’abat sur la Corée à la fin XVIIIe siècle et à laquelle le roi Jeongjo (r. 1776-1800) répond par des mesures sans précédent ? À quel type de pathologies peut-on associer les « désorganisations soudaines » (huoluan), qui peuvent être à l’origine de crises de morbidité ? Si on peut suivre la traduction en Chine du concept de microbe par celui de chong ou vermine21, les descriptions symptomatiques, les explications physiopathologiques d’une affection ou encore les ingrédients thérapeutiques prescrits dans les traités médicaux pré-modernes ne sont pas d’un grand secours pour tenter une adéquation avec les entités nosologiques bio-médicales : le regard et le discours médical pré-moderne s’articulent autour de déviances qui ne sont pas toujours significatives aux yeux d’un médecin moderne.

11 Si tenter un diagnostic a posteriori, sans les examens de laboratoire ou les traces paléo- pathologiques, reste toujours très hasardeux et, à ce titre, ne constitue pas la finalité des recherches de ce volume, il est possible en revanche de suivre la façon dont les phénomènes épidémiques sont perçus, éprouvés, catégorisés, jusqu’à faire l’objet de

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mesures que l’on qualifierait inadéquatement de « santé publique ». En évitant ainsi de projeter les catégories de la santé publique sur des épidémies nettement identifiées, les articles qui suivent retracent le sens du phénomène épidémique à partir des discours et des pratiques des acteurs qui les rencontrent. On retrouve ainsi la dimension imaginaire des épidémies, non comme un obstacle à leur identification précise, mais comme le moteur de leur prise en charge collective.

Les imaginaires de la menace

12 L’épidémie est d’abord une menace pour l’ordre public, qu’elle trouble de ses différents bords. En fragilisant l’ordre social et économique, une maladie entre en corrélation avec d’autres « fièvres », qui peuvent venir de l’intérieur ou de l’extérieur de la société. Cette menace, les contributions de ce volume la présentent sous différents traits.

13 Si l’histoire européenne fournit de multiples exemples d’épidémies mises sur le compte de l’étranger, les articles de William Johnston ou de Vincent Rollet montrent que le même raisonnement était à l’œuvre dans les sociétés asiatiques. Comme l’épidémie de choléra qui atteint le Japon au XIXe siècle est liée à l’arrivée des vaisseaux européens, les médecins japonais trouvent dans ces mêmes vaisseaux les traités médicaux pour décrire les symptômes : une telle corrélation autorise William Johnston à dire que c’est bien du même choléra que parlent les deux nations en présence. Le choléra, hautement contagieux, est dans un premier temps perçu comme une invasion de l’extérieur, en provenance de Java et de Chine, notamment ; au fil du temps, et à mesure que la maladie s’implante au Japon, elle devient aussi une maladie du lieu : fūdobyō. La gestion du SRAS à Taiwan, décrite par Vincent Rollet, illustre également cette peur de l’invasion étrangère. Le SRAS fut construit par les autorités taiwanaises comme un problème de sécurité nationale parce qu’il mettait en question les infrastructures vitales de la société, mais aussi parce qu’il arrivait du continent chinois : il fallait se préparer à une nouvelle épidémie comme on se prépare à une attaque militaire. Le SRAS fut décrit par les autorités chinoises comme une pneumonie atypique (feidian), mais sa désignation par l’OMS (Syndrome Respiratoire Aigu Sévère) a pu être associée, dans les articles de République Populaire de Chine, à l’acronyme de la Région Administrative Spéciale de Hong Kong (SAR, Special Administrative Region) et ainsi laisser penser à une épidémie d’origine étrangère.

14 La menace épidémique peut aussi être mise sur le compte de la désorganisation sociale ou de la décadence des mœurs. Ainsi, Shin Dongwon montre que, dans la Corée du XVIIIe siècle, le non-respect de certains tabous par la population, comme le déménagement des tombes à des moments non propices de l’année, est perçu par le peuple comme la principale cause de l’épidémie rouge hongyeok qui frappe alors le pays. C’est en creux que Florence Bretelle-Establet retrouve cette notion : en mangeant de façon équilibrée, en modérant ses passions et son style de vie, on se met à l’abri des miasmes tant redoutés de l’extrême sud de la Chine. Les mouvements de population à l’intérieur du territoire sont également perçus comme des troubles du corps social et des facteurs de propagation des épidémies : en dépit du silence politique des autorités centrales communistes, au cours de la Révolution culturelle étudiée par Fan Ka wai, quelques autorités locales mettent en rapport la flambée de méningite et les déplacements des étudiants venus écouter Mao Zedong à Pékin et honorer les lieux sacrés de l’histoire communiste.

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15 Enfin, l’environnement peut aussi constituer la source de l’épidémie. Florence Bretelle- Establet montre que, pour les médecins chinois de la fin de l’empire travaillant dans les régions de l’extrême sud, l’épidémie provient presque toujours d’un environnement pollué dont émane un qi putride et ubiquitaire affectant la collectivité. L’épidémie s’explique parfois par les changements dans l’environnement, et notamment dans les relations entre les hommes et les animaux. Christos Lynteris analyse les débats entre médecins occidentaux sur la peste bubonique en Mandchourie et la synthèse qu’en produit Wu Liande (Wu Lien-teh), médecin chinois formé en Angleterre. En montrant que la peste bubonique est transmise aux humains par les marmottes, ces médecins ne se contentent pas de reprendre un imaginaire de la saleté commune aux hommes et aux animaux, mais posent la question des origines de l’épidémie : pourquoi les chasseurs de marmottes ne sont-ils pas infectés ? Pourquoi les coolies qui les tuent pour le marché européen de la fourrure le sont-ils ? Y a-t-il un savoir local qui protège de la transmission de l’épidémie par les marmottes ? Les spéculations des médecins européens sur le rôle des animaux dans la transmission des épidémies ouvrent de nouvelles possibilités de combinaison, car on peut aussi bien imaginer que les marmottes soient infectées par les cadavres humains qu’elles dévoreraient.

16 Maladies générées par un cosmos déréglé, des environnements pollués, des divinités courroucées ou encore des envahisseurs étrangers, les épidémies ne laissent pas indifférentes les populations qui en subissent les assauts ni les administrateurs gouvernementaux.

Réponses apportées aux épidémies

17 Les réponses à la menace permettent de mesurer l’épreuve que constitue l’épidémie pour une société. En Asie orientale comme ailleurs, la société et ses élites peuvent d’abord recourir au large éventail des pratiques religieuses, visant à restaurer l’ordre bouleversé par l’épidémie. Les fonctionnaires chinois étudiés par Florence Bretelle- Establet ne se contentent pas d’adresser des prières aux divinités orthodoxes des fonctionnaires, les Dieux des Murs et des Fossés, pour éloigner les épidémies meurtrières qui ébranlent le au XIXe siècle, mais ils soutiennent aussi les processions populaires destinées à émouvoir les dieux des épidémies. « L’épidémie rouge » analysée par Shin Dongwon dans la Corée de la fin du XVIIIe siècle incite le roi Jeongjo à rétablir, dans le moindre de leurs détails, les rituels aux dieux des épidémies définis en 1403 mais rarement respectés depuis. Enfin, l’utilisation d’amulettes bouddhistes est préconisée dans le Japon du milieu du XIXe siècle pour chasser les démons locaux capables de semer le choléra. À travers ces actions de repentir, ces sacrifices rituels ou ces pratiques apotropaïques violentes, on entre donc en relation, sous différentes modalités, avec les « dieux des épidémies » et leurs acolytes, subalternes, les « démons épidémiques », perçus comme jouant un rôle majeur en Chine, en Corée ou au Japon, dans la propagation des épidémies22. La religion n’est pas non plus éloignée du discours des médecins occidentaux du début du XXe siècle, même si elle opère à un autre niveau. Les médecins occidentaux analysés par Christos Lynteris spéculent ainsi sur le rôle des pratiques lamaïstes dans la transmission de la peste bubonique. Alors que certains supposent que l’exposition religieuse des cadavres à ciel ouvert favorise la transmission de l’épidémie des humains aux marmottes, d’autres affirment au contraire que l’interdiction de consommer les marmottes limite la

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propagation – où l’on voit que le religieux est conçu comme une connaissance imparfaite ou tacite de l’environnement.

18 Si les imaginaires religieux permettent de décrire les réactions populaires aux épidémies, il est difficile de les analyser indépendamment de la mise en scène qui en est donnée par le pouvoir politique. L’épidémie constitue en effet toujours une épreuve pour la souveraineté du pouvoir, mis au défi d’instaurer des mesures visant à redéfinir l’espace sur lequel il s’exerce avec légitimité. La quarantaine, l’isolement, le confinement sont des façons d’exclure l’individu suspect, et ainsi de rétablir une frontière entre le sain et le malade. Comme l’ont montré différents chercheurs, la lèpre ou la variole ont, dans l’histoire chinoise, fait l’objet de telles mesures d’exclusion : dès le XVIe siècle, pour la première, et dès la fin du XVIIe, pour la seconde23. Dans la seconde partie du XIXe siècle, l’établissement des concessions étrangères et des ports ouverts a précipité et élargi ces pratiques dans le contexte plus large d’une « hygiène moderne24 ». La santé publique apparaît alors comme une façon pour le pouvoir d’affirmer sa souveraineté sur un territoire. Dans ce volume, l’article de Michael Shiyung Liu révèle combien la construction de la santé publique à Taiwan après 1949 ne peut se comprendre sans le contexte de la guerre sino-japonaise, qui a déterminé l’aide américaine apportée au gouvernement nationaliste, à travers un ensemble d’associations philanthropiques et caritatives. Lutter contre le paludisme à Taiwan dans les années 1950 dans le cadre des institutions de santé mises en place avec les États-Unis, c’est encore faire la guerre à un ennemi, comme l’illustre l’affiche alors en vogue à Taiwan et présentée dans l’article. Vincent Rollet montre combien la « sécuritisation des épidémies » en 2003-2005 permet au gouvernement taiwanais nouvellement élu de gagner en légitimité auprès de son peuple, mais aussi auprès des instances internationales, en se distinguant ostensiblement du gouvernement de la République Populaire de Chine, l’un communiquant ses cas, l’autre les occultant. Dans un contexte international de lutte contre les maladies infectieuses émergentes, la mobilisation de Taiwan contre le SRAS et la grippe aviaire apparaît comme une façon d’affirmer sa souveraineté nationale.

19 Une autre forme de réponse, destinée à assoir la légitimité de la souveraineté politique, mobilise moins le registre de la guerre et de la sécurité que celui de la surveillance et de la bienveillance. Le savoir épidémiologique a progressivement imposé une dimension d’anticipation dans la gestion des épidémies : il ne s’agit plus seulement de revenir à l’ordre ancien mais de changer les conduites qui ont causé la maladie. « À une protection des frontières de la communauté grâce aux lazarets, aux cordons militaires succède ainsi un ensemble d’efforts orientés vers l’amélioration des équipements sanitaires ainsi que vers une modification des comportements de la population25. » Cette dimension d’anticipation, aujourd’hui au cœur des politiques internationales de santé, n’était pas étrangère à la tradition médicale chinoise : le terme de yufang, « prévenir, prévention », est utilisé dans le Classique des Changements (Zhouyi) et nombre de textes anciens, y compris en Corée ou au Japon, soulignent la supériorité de celui qui sait se prémunir contre la maladie avant qu’elle ne soit déclarée. Cette prévention passait cependant par une hygiène individuelle privée composée de pratiques respiratoires, alimentaires, méditatives, et respectueuse de nombreux tabous26. William Johnston signale que cette importance accordée à la prévention dans la tradition japonaise a également contribué à la mise en place rapide d’une hygiène moderne et publique à la fin du XIXe siècle au Japon. L’anticipation est également au cœur des

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réponses du gouvernement coréen du roi Jeongjo, à la fin du XVIIIe siècle : à peine « l’épidémie rouge » s’est-elle déclarée que des mesures sont mises en place, en quelques jours seulement, pour limiter la propagation de la maladie et la souffrance générale du peuple ; de plus, demande est faite à tout le royaume de faire connaître à la cour les prescriptions les plus efficaces, et de les préparer, par anticipation, avant que ces épidémies cycliques ne terrassent à nouveau le pays ; dans la conceptualisation dominante de cette époque, le caractère cyclique et donc prévisible de ces épidémies s’explique par la théorie cosmologique des Cinq Mouvements et des Six souffles (wuyun liuqi). La mise en place de mesures d’urgence et le recours à toutes les forces du pays pour travailler à l’anticipation des prochaines épidémies inscrivent, selon Shin Dongwon, le gouvernement du roi Jeongjo dans une certaine modernité ; mais surtout, l’épidémie est ici une épreuve donnant l’occasion au souverain de manifester sa sollicitude à l’égard de son peuple et d’incarner les vertus cardinales qui font l’idéal du bon gouverneur confucéen, ayant à charge la gestion du pays et la santé du peuple (confondues en un seul caractère en chinois zhi).

20 Quand l’épidémie est conçue comme la propagation anormale d’une maladie naturelle, et non comme la résultante d’une punition divine, la gestion des médicaments est une des épreuves pour la souveraineté : il faut à la fois répondre en urgence par la distribution de produits adaptés, et anticiper par la constitution de stocks. Les sociétés asiatiques pratiquaient la variolisation à titre privé, et ce n’est qu’à partir de 1681 que l’empereur Kangxi l’imposa dans les « enclaves manchoues » aux frontières de l’Empire chinois27. L’article de Shin Dongwon montre que l’État coréen, au XVIIIe siècle, publia un plan de rationalisation des médicaments disponibles en cas d’épidémie. Lors de la Révolution culturelle, selon Fan Ka wai, l’épuisement des stocks de sulfadiasine et le manque de masques dans les hôpitaux contribuèrent à la propagation de l’épidémie de méningite cérébrospinale et au constat, par la CIA, de la perte du contrôle de l’épidémie par les autorités communistes centrales. Dans les années 2000, le même type de stockage de médicaments vise à éviter l’effondrement de la croissance économique du fait d’une épidémie de grippe qui entraverait les échanges, et à défendre le statut d’une nation dans le cadre de la « santé globale », comme le souligne Vincent Rollet pour le cas de Taiwan. L’épidémie catalyse tout un jeu complexe de producteurs et de prescripteurs de médicaments dans une logique d’anticipation qui teste la capacité des pouvoirs publics à protéger la population.

Les incertitudes du collectif

21 On pourrait penser que l’avènement des théories pastoriennes et de la médecine de laboratoire dans les dernières décennies du XIXe siècle, qui permirent de comprendre certains des mécanismes liés aux épidémies de maladies infectieuses, modifie radicalement les différentes figures que prennent la menace épidémique et les réponses qui lui sont apportées. En somme, il devrait y avoir un avant et un après, ce qui permettrait d’instaurer une coupure pratique dans ce volume entre les contributions portant sur la notion d’épidémie avant le XIXe siècle et celles qui traitent de la période contemporaine. Le matériau apporté par ce volume bouscule un tel ordonnancement en montrant que la conceptualisation de la menace épidémique et les différentes formes de réponses qui lui sont apportées ne sont pas fondamentalement différentes

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d’une période à l’autre et n’obéissent pas seulement aux progrès d’une rationalité scientifique.

22 L’article de Christos Lynteris montre ainsi que les enquêtes scientifiques menées par des médecins français et russes visant à déterminer l’origine et les mécanismes de la diffusion de la peste dans le Nord de la Chine au tournant du XXe siècle s’enchaînent moins comme les étapes d’un progrès linéaire que comme des transformations « épidémio-logiques » autour d’une incertitude fondamentale : que révèle la peste des relations entre les hommes et les marmottes dans un environnement en plein changement ? Les articles de Shin Dongwon sur la Corée de la fin du XVIIIe siècle ou de Fan Ka wai sur la Chine communiste des années 1960 bouleversent l’idée d’une rationalité scientifique appliquée progressivement au contrôle des épidémies. C’est sans connaître le mécanisme de transmission des maladies infectieuses mais en liant le phénomène épidémique à une cosmologie déréglée que le roi coréen Jeongjo, à la fin du XVIIIe siècle, s’active à quadriller la société, à assigner des médecins à chaque quartier, à approvisionner en remèdes coûteux la population la plus démunie. C’est en connaissance des principes de transmission de la méningite cérébro-spinale que le gouvernement communiste poursuit sa politique de mobilisation des masses malgré une épidémie déjà déclarée. L’épidémie véhicule bien plus que l’idée d’une surmorbidité ou d’une surmortalité ; quelle que soit la période considérée, elle est une menace pour l’ordre politique, social, économique qui met en branle des réponses allant bien au-delà de la stricte rationalité médicale.

23 Suivre les réponses à l’épidémie (religieuses, militaires, médicales), c’est donc aussi être attentif aux recompositions du collectif lorsqu’il apparaît à la fois comme cause et comme remède d’une maladie. Les médecins européens ont-ils introduit le choléra ou ont-ils permis aux médecins japonais de le soigner ? Les gardes rouges ont-ils propagé ou traité la méningite dans la ferveur religieuse de la Révolution culturelle ? Nous avons voulu laisser ouvertes ces questions suscitées par les contributions proposées, car l’un des enseignements des épidémies récentes est la capacité des pouvoirs publics à reconnaître l’incertitude sur les agents infectieux lorsqu’ils se diffusent dans un collectif de plus en plus large, et à intégrer un grand nombre d’acteurs pour composer une réponse pertinente.

BIBLIOGRAPHIE

ANDREWS Bridie (1997). « Tuberculosis and the Assimilation of Germ Theory in China, 1895-1937 ». Journal of the History of and Allied Sciences, vol. 52-1: 114-157.

ARNOLD David. (1993). Colonizing the Body. State Medicine and Epidemic Disease in Nineteenth Century . Berkeley, University of California Press.

BOURDELAIS Patrice (2003). Les Épidémies terrassées. Une histoire de pays riches. Paris, La Martinière.

BRETELLE-ESTABLET Florence (2002). La Santé en Chine du Sud (1898-1928). Paris, CNRS Éditions.

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DELAPORTE François (2004). « Épidémie ». In Dominique Lecourt (dir.), Dictionnaire de la pensée médicale. Paris, PUF : 418-425.

DELUMEAU Jean (1978). La Peur en Occident. Paris, Fayard.

DESPEUX, Catherine et OBRINGER, Frédéric (1997). La Maladie dans la Chine médiévale. La toux. Paris, L’Harmattan.

FAN, Xingzhun 范行準 (1953). Zhongguo yufang yixue sixiang shi 中國預防醫學思想史 (Histoire de la pensée médicale préventive en Chine). Shanghai, Huadong yiwu shenghuo shi.

FASSIN, Didier (2006). Quand les corps se souviennent. Expérience et politiques du sida en Afrique du Sud. Paris, La Découverte.

FEE Elizabeth & PORTER Dorothy (1992). « Public Health, Preventive Medicine and Professionalization: England and America in the Nineteenth Century ». In Andrew Wear (dir.), Medicine in Society: Historical Essays. Cambridge, Cambridge University Press: 249-275.

GUILLAUME Pierre (1996). Le Rôle social du médecin depuis deux siècles. Paris, Association pour l’étude de l’histoire de la sécurité sociale.

GREENFELD Karl Taro (2006). Le Syndrome chinois. La première grande épidémie du XXIe siècle. Paris, Albin Michel.

HANSON Marta (2011). Speaking of Epidemics. Disease and the Geographic Imagination in Late Imperial China. Londres/New York, Routledge, « Needham Research Institute Series ».

HANSON Marta (à paraître). « Visualizing the Geography of Diseases, 1870s-1920s. An Overview of the Earliest Disease Maps of China ».

HEINRICH Larissa (2008). The Afterlife of Images: Translating the Pathological Body Between China and the West. Chapel Hill, Duke University Press.

KATZ Paul (1995). Demon Hordes and Burning Boats: The Cult of Marshal Wen in Late Imperial Chekiang. Albany, State University of New York Press.

KECK Frédéric (2010). « Une sentinelle sanitaire aux frontières du vivant. Les experts de la grippe aviaire à Hong Kong ». Terrain, no 54: 26-41.

LEUNG Angela Ki Che (2009). in China: A History. New York, Columbia University Press.

MACPHERSON Kerrie L. (1987). A Wilderness of Marshes. The Origins of Public Health in Shanghai (1843-1893). Oxford, Oxford University Press.

MASON Katherine (2010). « Becoming Modern after SARS. Battling the H1N1 Pandemic and the Politics of Backwardness in China’s Pearl River Delta ». Behemot. A Journal on Civilisation, no 3: 8-35.

MCNEILL William (1976). Plagues and Peoples. New York, Anchor Books.

MICOLLIER Évelyne (dir.) (2009). « La société chinoise face au SIDA ». Perspectives chinoises, no 1.

MONNAIS-ROUSSELOT Laurence (1999). Médecine et colonisation. L’aventure indochinoise (1860-1939). Paris, CNRS Éditions.

MOULIN Anne-Marie (1996). L’Aventure de la vaccination. Paris, Fayard.

NEEDHAM Joseph et LU Gwei-Djen (1962). « Hygiene and Preventive Medicine in Ancient China ». Journal of the History of Medicine and Allied Sciences, vol. 17-4: 429-478.

ROGASKI Ruth (2004). Hygienic Modernity: Meanings of Health and Disease in Treaty-Port China. University of California Press.

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ROSENBERG Charles (1992). Explaining Epidemics and other studies in the history of medicine. Cambridge, Cambridge University Press.

SCHIPPER Kristofer (1985). « Seigneurs royaux, dieux des épidémies ». Archives des Sciences Sociales des Religions, 59, 1 : 31-52.

SHORTRIDGE K. F. et STUART-HARRIS C.H. (1982). « An Influenza Epicentre? ». Lancet, no ii: 812-813.

WINSLOW Charles (1943). The Conquest of Epidemic Diseases. Princeton, Princeton University Press.

ANNEXES

Glossaire

Yi 疫 Liuxing 流行 Wenyi 瘟疫 Wenyi 温疫 Wenbing 温病 sizhe wusuan 死者無算 shiyi 時疫 jiyi 疾疫 zaili 災癘 huoluan 霍亂 chong 蟲 hongyeok 紅疫 fūdobyō 風土病 feidian 非典 yufang 預防 wuyun liuqi 五運六氣 zhi 治

NOTES

2. Delumeau 1978 : 132. 3. Rosenberg 1992. 4. McNeill 1976. 5. Delaporte 2004. 6. Winslow 1943. 7. Le Point (dernier accès 28 mars 2014). http://www.lepoint.fr/editos-du-point/anne-jeanblanc/ de-nouvelles-maladies-emergentes-a-redouter-14-11-2012-1528856_57.php 8. Greenfeld 2006. 9. Shortridge et Stuart-Harris 1982. 10. Keck 2010. 11. Bourdelais 2003 : 9. 12. Heinrich 2008. 13. Bretelle-Establet 2002.

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14. Ces ouvrages développent à la fois un projet cartographique destiné à mettre en évidence des liens de causalité entre épidémies et environnements et, en même temps, une image de l’espace chinois ou indochinois contrastant avec celui de l’Europe. Sur l’usage et les fonctions de ces cartes médicales, cf. Hanson, à paraître ; Monnais-Rousselot 1999. 15. Fee et Porter 1992 ; Guillaume 1996. 16. Micollier 2006 ; Fassin 2006. 17. Mason 2010. 18. Fan Xingzhun 1987 : 263-275. Différentes expressions shiyi, jiyi, zaili ont été utilisées mais le terme yi, associé aux caractères wen (clé de la maladie) ou wen (clé de l’eau), semble le plus courant. 19. Hanson 2011. 20. La question a été soulevée par de nombreux historiens, dont Despeux et Obringer 1997 : 20, au sujet de la toux. 21. Andrews 1997. 22. Schipper 1985 ; Katz 1995. 23. Leung 2009 : 96-111. Les premiers asiles sont créés à la fin du xvie siècle, mais la majeure partie date du xviiie siècle. Par crainte d’attraper la variole, les manchous qui n’ont pas d’immunité contre la maladie en viennent à dessiner une ville entièrement interdite aux Chinois. (Hanson 2011.) 24. MacPherson 1987 ; Rogaski 2004. 25. Bourdelais 2003 :12. 26. Cf. Fan Xingzhun 1953 : 8. Needham et Gu 1962. 27. Moulin 1996.

AUTEURS

FLORENCE BRETELLE-ESTABLET

FLORENCE BRETELLE-ESTABLET is researcher in SPHERE team (UMR 7219, CNRS/Université Paris- Diderot). Since her PhD (1998), she has worked on the history of medicine in late imperial China. Author of La Santé en Chine du Sud. 1898-1928 (2002), she has published articles and book chapters on the history of medicine in the Far South of China and edited several books, notably Looking at It from Asia: The Processes that Shaped the Sources of History of Science (2010). With Romain Graziani, she is the chief editor of the journal Extrême-Orient, Extrême Occident. FLORENCE BRETELLE-ESTABLET est chargée de recherche dans l’équipe SPHERE (UMR 7219, CNRS/ Université Paris-Diderot). Depuis sa thèse (1998), elle travaille sur l’histoire de la médecine en Chine, à la fin de l’empire. Auteure de La Santé en Chine du Sud. 1898-1928 (2002), elle a publié des articles et des chapitres de livre sur l’histoire de la médecine dans le Sud de la Chine et dirigé plusieurs livres, notamment Looking at It from Asia : The Processes that Shaped the Sources of History of Science (2010). Avec Romain Graziani, elle est rédactrice en chef de la revue Extrême-Orient Extrême-Occident.

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FRÉDÉRIC KECK

FRÉDÉRIC KECK est membre Laboratoire d’anthropologie sociale (UMR 7130) et directeur du département de recherche au Musée du quai Branly. Entré au CNRS en 2005, il a travaillé sur la question de l’anticipation des épidémies au niveau animal. Il a publié Un monde grippé (2010) et, avec Noelie Vialles, Des hommes malades des animaux (2012), ainsi que, avec Andrew Lakoff, Sentinel Devices (2013).

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I. Imaginaires des foyers Imagined Sources

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Les épidémies en Chine à la croisée des savoirs et des imaginaires : le Grand Sud aux XVIIIe et XIXe siècles Epidemics in China at the Crossroads of Knowledge and the Imagination: The Far South of China in the 18th and 19th Centuries 十八至十九世紀中國南方的疫病知識與想像

Florence Bretelle-Establet

1 Cet article examine les sens qu’on prête aux épidémies en Chine, avant la diffusion d’une compréhension du phénomène épidémique fondée sur les découvertes de laboratoire. Comme les articles de Christos Lynteris ou de William Johnston le rappellent dans ce volume, ces avancées, au tournant du XXe siècle, permettent à la communauté scientifique internationale de comprendre certains des mécanismes de transmission et de diffusion des maladies infectieuses et inspirent en retour des politiques de prévention nouvelles. En Chine, le projet d’installer des institutions chargées de surveiller les épidémies prend forme dans la première décennie du XXe siècle, dans le cadre d’un ensemble de réformes connu sous le nom de « Politique Nouvelle » (xinzheng)1. Notre propos se situe en amont de cette période charnière et se concentre sur une partie de ce qu’il est convenu d’appeler « la fin de l’empire », les XVIIIe et XIXe siècles, période au cours de laquelle des épidémies particulièrement meurtrières sévissent dans le pays. Ce n’est certes pas la première fois que la population et ses élites subissent l’offensive de maladies faisant, en peu de temps, « un nombre incalculable de morts » (sizhe wusuan), pour reprendre l’expression la plus couramment utilisée en rapport avec le signalement d’épidémies (yi). Les sources historiques ont en effet conservé les traces de ces fléaux qui touchèrent la Chine à maintes reprises et les historiens ont commencé à mettre au jour les réponses politiques et les changements épistémologiques que ces épisodes provoquèrent au sein des élites politiques et médicales2. L’objet du présent article est d’esquisser la carte des savoirs et des pratiques qui sous-tendent la notion d’épidémie, à la veille de la mise en place d’institutions chargées de les surveiller, les contrôler et les combattre, sur la base

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des connaissances médicales, acquises au sein du laboratoire. Ceci nous amènera à nous concentrer sur l’extrême sud de la Chine qui devint, à partir du XVIIIe siècle, le siège d’épidémies récurrentes rapportées par les observateurs chinois puis par les observateurs étrangers. En étudiant les initiatives individuelles ou politiquement orchestrées, en scrutant la littérature médicale contemporaine de cette vague épidémique et produite dans cet espace particulier, nous mettrons en lumière les manières dont les épidémies sont alors comprises et combattues.

L’épidémie : une anomalie administrativement consignée

Des épidémies inédites sur un vieux fond miasmatique

2 L’extrême sud de la Chine, comptant les provinces du Yunnan, du et du , est depuis longtemps affublé de la réputation d’être le siège de zhang « miasmes » qui effraient ceux qui doivent s’y rendre et que le ministère des châtiments réserve, comme punition, aux fonctionnaires pris en faute3. À la fin du XVIIIe siècle, à cette crainte du zhang s’ajoute celle des épidémies. Les prières adressées en 1823, puis en 1830, au Dieu des Murs et des Fossés Chenghuangshen, par Cheng Hanzhang (ca 1763-1832), natif de la région de Jingdong au Yunnan, en témoignent. Alors qu’il est Gouverneur de la province du Jiangxi, Cheng écrit : Depuis 1789, la terre et les montagnes se sont mises à trembler et les épidémies yiwen n’ont cessé de faire des ravages de façon harcelante pendant trente-cinq ans. Certains ont des démangeaisons sheng yangzi, d’autres ont des furoncles qi maoding, d’autres ont les pieds et les mains engourdis et paralysés shouzu mamu buren, d’autres ont le visage hagard et de la fièvre toumianhunkuang er zuore. Homme à l’aube, fantôme au crépuscule. Sur dix atteints, un seul survit. Quand le mal débute, il gagne toutes les directions et n’épargne aucune famille. À la fin de l’été et au début de l’automne, toutes les familles connaissent la cruauté de la séparation. Les cadavres et les cercueils sont éparpillés dans les champs, le ciel est empli d’une odeur putride […]. Des familles entières sont décimées, des hameaux tombent en ruine. Dans certains villages, la mortalité touche deux à trois habitants sur dix, dans certains bourgs, elle atteint cinq à six habitants sur dix. On ne sait combien il y a eu de morts dans les soixante quatorze districts, sous-préfectures et préfectures, des centaines de milliers, hélas !

3 Sept ans plus tard, et tandis qu’il est gouverneur des affaires civiles de la province du Fujian, il réitère sa prière contre des épidémies qui, associées désormais à des démangeaisons (sheng yangzi), des crampes du mollet (zu zhuanjin), des vomissements de sang (tu hongxue) et des diarrhées (xieli), bousculent l’ordre économique et appauvrissent la région4. Ces prières, sur lesquelles nous reviendrons, ne sont pas des témoignages isolés sur une situation inédite. La biographie du médecin Xu Gaoyi, originaire du Yunnan, signale également l’apparition d’épidémies violentes au cours de l’ère Jiaqing (1796-1820)5. Plus largement, les chroniques locales du Sud de la Chine, dans leurs chapitres réservés à enregistrer les événements inhabituels du lieu, signalent, à partir de la fin du XVIIIe siècle, l’apparition d’épidémies yi ou wenyi exceptionnellement rapprochées6. La chronologie et la spatialisation de ces épisodes, établies sur la base d’un dépouillement de nombreuses chroniques locales, font apparaître deux grandes vagues épidémiques : une première, que les prières ci-dessus évoquent avec pathétisme, débute dans la province du Yunnan en 1772 et s’achève en

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1830 ; une seconde déferle vingt ans plus tard : en l’espace de quarante-quatre ans, de 1854 à 1898, des épidémies sont mentionnées près de deux cents fois en différentes parties du Yunnan. Si la première vague épidémique semble circonscrite à la province du Yunnan, la seconde, qui se trouve désormais documentée par de nouveaux observateurs – missionnaires, médecins, diplomates ou marchands européens –, touche également les provinces du Guangxi et du Guangdong7.

La peste bubonique et les autres maladies en cause

4 Malgré les difficultés que pose tout diagnostic a posteriori, liées à la rareté des observations cliniques, souvent peu spécifiques, inscrites, de surcroît, comme le montrent les prières ci-dessus, dans un cadre conceptuel qu’il est malaisé d’adapter à celui d’une sémiologie moderne, les historiens ont tenté d’identifier la nature de ces épidémies. En confrontant les sources chinoises, dont certaines signalent l’apparition de signes et symptômes distinctifs – les épizooties de rats précédant les épidémies humaines et l’apparition de bubons sur le corps –, avec les premiers témoignages occidentaux, au début des années 1870, en s’aidant des connaissances modernes de l’épidémiologie et de la géographie médicale, Carol Benedict a notamment établi que l’entité nosologique responsable des épidémies yi en Chine méridionale aux XVIIIe et XIXe siècles est la peste bubonique, maladie infectieuse transmise à l’homme par la puce du rat, infestée par le bacille de la peste. L’expansion de cette maladie est, selon elle, imputable à des changements économiques et sociaux importants dans la région. L’intensification de l’exploitation des mines de cuivre au Yunnan, à partir de 1723, la forte immigration qui en résulte ainsi que l’ouverture ou la réouverture de routes pour le commerce, favorisent, dès la fin du XVIIIe siècle, l’expansion de la maladie dans une population plus dense et sur de plus longues distances. Après une accalmie liée au déclin économique du Yunnan, les mouvements de troupes et de migration lors de la rébellion musulmane (1856-1873) réactivent la diffusion de la maladie dans la province. Dans le même temps, l’accroissement du commerce d’opium entre le Yunnan et le port de Canton, les opérations militaires entre soldats et derniers rebelles du mouvement des Taiping confinés dans le Guangdong occidental et le Guangxi contribuent à l’expansion de l’épidémie de peste du Yunnan vers ces provinces8. La peste gagne ainsi la côte, provoquant, en 1894, une épidémie particulièrement spectaculaire dans les ports de Canton et de Hongkong.

5 Si une partie, peut-être même la majeure partie, des épidémies recensées par le caractère yi ou wenyi a correspondu à la peste bubonique, il est aussi certain que d’autres maladies infectieuses sont en cause. Les biographies des médecins du Sud de la Chine apportent un contrepoint à la chronologie des épidémies reconstituée à partir des signalements de catastrophes dans les chroniques locales et à la nature des maladies incriminées. Certaines biographies signalent en effet l’existence d’épisodes épidémiques dans la province du Guangdong et du Guangxi bien avant la seconde moitié du XIXe siècle, et donc avant l’apparition de la peste bubonique dans la région : la biographie de He Yu, un homme de la sous-préfecture de Xiangshan, au Guangdong, et celle de Xie Wenhui, originaire de Nanhai mais par la suite établi au Guangxi, signalent l’apparition d’épidémies au Guangdong dès la fin du XVIIIe siècle9. De plus, certaines biographies signalent l’existence d’épidémies causées par des maladies qui ne correspondent pas à la peste bubonique. Les biographies de Huang Tingju et de Li

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Runguang, originaires de la province du Guangdong, ou celle de Yao Wenzao, un médecin probablement actif dans la seconde partie du XIXe siècle au Yunnan, témoignent, par exemple, de la virulence d’épidémies de variole10. Les préfaces d’un ouvrage consacré à la maladie baihou, littéralement « gorge blanche » et qui traduit aujourd’hui la « diphtérie », écrit par un lettré en poste au Guangxi, dans la seconde moitié du XIXe siècle, rapportent l’apparition dans la région d’épidémies causées par cette maladie affectant la gorge et coïncidant mal avec l’entité de la peste bubonique11.

6 Ces témoignages ne remettent pas en question la correspondance faite par Carol Benedict et d’autres historiens entre le caractère yi et la peste bubonique dans cet espace-temps, ni l’histoire de la diffusion de la peste dans le Sud de la Chine ; ils signalent plutôt qu’à cette épidémie de peste bubonique progressant d’ouest en est, au fil du XIXe siècle, s’ajoutent des épidémies causées par d’autres maladies que la peste bubonique. Les témoignages des observateurs étrangers le confirment.

Des épidémies passées au crible du microscope au tournant du XXe siècle

7 Les médecins occidentaux envoyés dans les dernières décennies du XIXe siècle dans les concessions, les ports ouverts ou dans les territoires à bail, munis d’un bagage intellectuel nouveau qui les pousse à examiner sous le microscope la nature des maladies qu’ils rencontrent et qui menacent la vie et les intérêts de leurs compatriotes, sont une nouvelle source de renseignement sur l’ampleur et parfois la nature des épidémies qui sévissent dans le Sud de la Chine. Sans entrer dans le détail d’une chronologie morbide qui souffre, en ce tournant de siècle, de l’absence d’infrastructures qui permettraient un tableau épidémiologique exact, il est loisible de résumer à grands traits ce que ces observateurs étrangers alors remarquent. Les médecins militaires français, envoyés dans cette partie de la Chine pour renseigner le Gouvernement général de l’Indochine des risques épidémiologiques en provenance de la Chine, sont formels : les épidémies de peste dans la partie centrale de la province du Yunnan ont cessé de faire des victimes depuis 1895 mais la partie occidentale de la province continue à en subir les ravages. Dans les provinces du Guangxi et du Guangdong, et surtout dans les ports, la situation est différente : mentionnée à Beihai, dès 1867, la peste est signalée chaque année jusqu’en 1913 et revient fréquemment jusqu’en 1919 sur le littoral nord de l’île de Hainan, reliée à la péninsule de par un trafic important. En fait, tous les témoignages de cette époque s’accordent sur le sens de l’expansion de la peste : elle diminue au cours des quarante premières années du XXe siècle dans la province du Yunnan et ravage davantage les provinces du Guangdong et du Fujian.

8 Mais la peste n’est pas la seule maladie responsable des phénomènes épidémiques qui touchent la Chine du Sud. Le choléra, introduit en Chine dans les années 1820-1822, lors de ce qu’il est convenu d’appeler la première pandémie, est à l’origine d’une quarantaine d’épidémies entre 1820 et 1932. Mentionnée en 1820 en différentes parties du Guangdong, la maladie gagne les provinces intérieures du Guangxi et du Yunnan les années suivantes. Si la chronologie des épidémies de choléra reste à faire pour ces régions de la Chine, quelques témoignages indiquent que les populations méridionales ne sont pas épargnées par cette maladie hautement contagieuse : à Canton, en 1863, l’épidémie, selon Dudgeon, cause sur plusieurs semaines la mort de

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1500 malades par jour. De l’avis des observateurs français, le choléra visite presque chaque année la population cantonnaise, pendant les dernières décennies du XIXe siècle. Dans l’île de Hainan, la maladie cause en 1879 une épidémie particulièrement meurtrière. Les régions intérieures ne semblent pas épargnées : s’il paraît inconnu dans la ville de Kunming, à la fin du XIXe siècle, le choléra est néanmoins signalé en 1883 aux environs de Dali comme le fléau le plus commun ; il provoquera en 1918 et 1919 dans le centre minier de Gejiu, au sud de la province du Yunnan, une épidémie emportant le cinquième des habitants.

9 Malgré la pratique courante de la variolisation et les vaccinations antivarioliques introduites dans la province du Guangdong au début du XIXe siècle, les épidémies de variole mentionnées dans quelques biographies de médecins chinois sont régulièrement consignées par les observateurs étrangers jusque dans les premières décennies du XXe siècle. À ces fléaux, s’ajoutent la diphtérie, la scarlatine, la dengue ou la grippe qui se propagent sous la forme d’épidémies très meurtrières dans cette partie de la Chine à la charnière des XIXe et XXe siècles12.

10 Pour les observateurs chinois de la fin de l’empire comme pour les observateurs occidentaux, le Sud de la Chine est donc fréquemment soumis aux assauts des épidémies et tous ont laissé des témoignages qui en font état. L’épidémie, en particulier de peste ou de choléra, prend partout l’allure d’une catastrophe. À ce titre, elle suscite des réactions fortes dans toutes les sociétés, dont témoigne le grand nombre de récits et de peintures qu’elle a inspirés. Les réponses apportées à cette crise sont généralement conditionnées par les croyances étiologiques et physiopathologiques que chaque société véhicule et qui varient dans l’espace et dans le temps13. Dans cette partie de l’Empire chinois, comment affronte-t-on les épidémies et quels sens leur accorde-t- on ?

L’épidémie à la fin de l’empire : un phénomène toujours démonologique

Les processions pour calmer les dieux des épidémies, les wenshen

11 Il est difficile d’avoir des sources écrites émanant directement du commun des mortels pour comprendre le sens qu’il accorde alors, dans cette partie de la Chine, aux épidémies. Deux types de sources indirectes apportent néanmoins un éclairage : les chroniques locales, dans le chapitre des coutumes populaires fengsu ; les descriptions des observateurs étrangers qui, en même temps qu’ils signalent les incidences épidémiques, rapportent aussi les réponses indigènes qu’ils parviennent à voir.

12 Ce sont surtout les processions collectives conduites en temps d’épidémie qui ont retenu l’attention des observateurs étrangers. C’étaient des pratiques voyantes, bruyantes, colorées, particulièrement animées. C’était aussi aux yeux des observateurs occidentaux de la fin du XIXe siècle, à l’affût des microbes et défenseurs de l’isolement prophylactique (le rôle de la puce du rat n’étant découvert qu’en 1898, la prophylaxie européenne reste jusqu’aux dernières années du XIXe siècle celle de l’isolement des malades avant de se tourner vers l’éradication des rats et des puces), des pratiques collectives des plus inadaptées. Ainsi le Dr Rouffiandis rapporte en détail la procession qu’il a vu défiler lors d’une épidémie de peste à Fuzhou en 1902 :

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Les Chinois se livrent, pendant une épidémie de peste, à une foule de cérémonies d’ordre religieux destinées, disent-ils, à chasser les diables de la peste. La plupart des cérémonies se rattachent au culte de la mémoire des cinq grands personnages, sorte de demi-dieux ou de génies protecteurs contre la peste et aussi contre les autres maladies épidémiques (choléra, variole). Il y a dans chaque quartier de Foutchéou un temple spécial pour ces cinq génies […]. En temps d’épidémie, les cinq statues sont sorties du temple et promenées en grande pompe dans les rues. Le cortège est parfois très beau et très pittoresque : le 30 juillet, à 8 heures du soir, j’ai vu ainsi défiler une de ces processions qui ne comprenait pas moins d’un millier de personnes. Le cortège est formé d’une foule de figurants divers escortant les statues des cinq génies portées dans des chaises à porteurs […]. À la fin du cortège, est un bateau en bambou et en papier, orné de fleurs et de broderies, qui représente le vaisseau « où les diables mettent les pestiférés pour les emmener dans l’au-delà ». Après avoir parcouru les principales rues de la ville, le cortège se rend au pont HouangtsanKiao situé sur le Min à huit kilomètres environ de la ville, d’où le tableau est précipité dans les eaux ; après quoi, le cortège revient et rapporte les statues dans leur temple14.

13 Les processions, signalées à Beihai en 1910 ou à Haikou en 192615, répondent alors à une croyance généralement partagée des épidémies, alimentée par deux traditions : une tradition ancienne qui remonte à la Chine antique des Shang et des Zhou et qui explique l’épidémie comme l’intervention capricieuse et maléfique des esprits, ancêtres défunts ou autres, qu’on devait chasser à renfort de rituels exorcistes ou d’incantations ; une tradition plus tardive qui s’élabore aux IIIe et IVe siècles au sein d’une religion populaire, mêlant différents éléments du taoïsme, du bouddhisme et du confucianisme, et qui conçoit l’épidémie comme une punition collective, envoyée par des puissances divines. Dans cette religion populaire, un ministère des épidémies wenbu est imaginé parmi une dizaine d’autres au sein de la Bureaucratie céleste, dirigée au sommet par Yuhuang, l’Empereur de Jade. Comme les autres ministères, celui des épidémies a un président, des assistants et des fonctionnaires subalternes, chargés de surveiller la communauté des vivants et de faire un compte rendu annuel de ses fautes et de ses mérites. En fonction des agissements plus ou moins mauvais des humains, l’Empereur de Jade peut envoyer comme punition collective une épidémie par l’intermédiaire de ces fonctionnaires auxquels se mêlent des démons épidémiques yigui, beaucoup plus incontrôlables16. À ces conceptions étiologiques répondent deux sortes de pratiques qui parfois s’imbriquent dans une cérémonie bigarrée : des actions de repentir et des pratiques apotropaïques violentes.

14 La procession décrite par Rouffiandis honore les Cinq Commissaires des Épidémies wuwen shezhe, qui seraient apparus en l’an 591 au fondateur des Sui (589-618). Après une épidémie très meurtrière, l’empereur aurait demandé qu’on érigeât un temple pour ces cinq personnages qui, à partir de cette époque, font l’objet d’un culte le cinquième jour du cinquième mois lunaire17. Pratiqué régulièrement à Fuzhou depuis le XVIIe siècle, ce culte s’est ensuite implanté à Taiwan18. Honorer ces divinités était jugé particulièrement efficace pour prévenir la localité d’une épidémie ; les brandir en arrêtait la marche. Mais en Chine, comme dans l’Europe christianisée, il n’y a pas qu’un seul type de divinités capables de propager ou retenir l’épidémie. Un culte était aussi rendu au Maréchal Wen Yuanshuai au troisième mois de l’année, au Zhejiang, tandis qu’à Taiwan on honorait tous les trois ans les douze Seigneurs Royaux Wangye19. Le médecin Broquet rapporte qu’au cours de l’épidémie de peste qui a régné dans la concession française de en 1901, le Bouddha du village Palap ( ?) qui passait pour avoir protégé son village l’année précédente est emprunté et porté en

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grande pompe dans le village voisin de Potao (Potou)20. A Kunming, au début du XXe siècle, c’est la déesse Guanyin qui fait l’objet d’un culte préventif chaque année, à date fixe, destiné à empêcher le développement des maladies contagieuses21.

15 Si les divinités honorées varient d’un lieu à l’autre, beaucoup d’ingrédients composant ces cultes et rappelant la cérémonie ancienne d’exorcisme Danuo sont communs : ils durent quelques jours au cours desquels des offrandes sont faites dans des temples, des pièces de théâtre y sont jouées, puis une procession défile dans les rues, se clôturant par la mise à l’eau ou par l’incendie d’un bateau-dragon censé prendre les démons de la peste au passage22.

Les mesures d’exorcisme pour chasser ou tromper les diables épidémiques, les yigui

16 À ces cultes s’ajoutent les mesures d’exorcisme destinées à lutter contre les démons des épidémies (yigui). Ainsi, au , un rituel (qing jiao) se tenait le deuxième jour du troisième mois : chaque printemps, les habitants des villes et des campagnes réunissaient une somme d’argent, fabriquaient un bateau-dragon, des wu (sorciers) se peignaient le visage à l’encre rouge pour imiter les dieux du panthéon et recherchaient dans chaque maison les démons de façon à repousser l’épidémie. Des rituels similaires s’exécutent au Guangxi sous le nom de « rituel pour la tranquillité » (ping an jiao)23. Mais la recherche et l’expulsion des démons se mènent aussi en temps d’épidémie, tambour battant. Le médecin Koang-ting Lo, originaire de Beihai et formé à la médecine occidentale dans les années 1920, explique l’origine des mesures prises par ses compatriotes en temps d’épidémie de peste : La mort insolite des rats est considérée… comme une manifestation de la colère des dieux ou démons. S’ils constatent le fait dans leur maison, ils ont immédiatement recours à des sorciers pour chasser les diables malfaisants. Ces derniers emploient des solutions inflammables qu’ils projettent par la bouche ou en soufflant dans une sorte de vaporisateur sur une torche allumée. Ils promènent rapidement cette torche dans les endroits obscurs de la maison. La scène se termine par des manifestations bruyantes dans l’espérance illusoire de faire fuir les diables en question loin de la maison24.

17 Une chronique de Liujiang, dans le Guangxi, déplore en 1937 la survivance de faits similaires : « En temps de maladie épidémique bingyi […] on façonne avec des herbes un dragon, on le remplit d’encens et on allume un feu au sommet. On le fait déambuler dans tous les endroits, en faisant résonner gongs, tambours et cors. Les gens l’accueillent en faisant claquer des pétards, car il est dit qu’il peut chasser les maladies épidémiques qu yili25. »

18 À la fin de l’empire, les épidémies sont donc au cœur de pratiques religieuses et exorcistes qui perdureront jusque dans la première partie du XXe siècle26. Ces pratiques ne semblent pas distinguer la population ordinaire des autorités qui, contrairement à ce qu’en disent les médecins occidentaux présents en Chine, participent à la lutte. Certes, cette lutte ne ressemble pas à celle qui, depuis le milieu du XIXe siècle, se met en place en , en Europe ou aux États-Unis, où les gouvernements se donnent le droit et le devoir d’imposer aux individus des règles d’hygiène pour le bien de la collectivité, où des comités consultatifs d’hygiène sont chargés d’éclairer les plus hautes autorités sur les mesures à prendre en temps d’épidémie27. Ici, comme ailleurs, les autorités publiques s’activent à écarter les épidémies de leur juridiction, en fonction de

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l’étiologie en laquelle elles croient : elles accompagnent et soutiennent financièrement les processions, comme le soulignent le consul de France à Canton au cours de la peste de 1894 ou le médecin en poste à Beihai lors de l’épidémie de 191028. Elles avancent le calendrier, célèbrent une nouvelle année en pleine épidémie dans l’espoir d’induire les démons épidémiques en erreur. Ces pratiques sont rapportées pour la ville de Canton en 1894 et pour celle de Fuzhou en 1902 où des avis, publiés par les plus hautes autorités, consacrent respectivement le 1er jour du 4e mois et le 22e du 5e mois, selon le calendrier lunaire, comme premier jour de l’année29. Enfin, les autorités sollicitent la bienveillance du Dieu des Murs et des Fossés local comme les prières mentionnées plus haut en témoignent. Incarnation symbolique d’un personnage historique ou d’un héros local réel ou imaginaire, ce Dieu est sous le commandement de l’Empereur de Jade, et constitue le dieu orthodoxe auquel s’adressent les fonctionnaires lorsque la circonscription est accablée par des désastres en tout genre comme les épidémies30. Ainsi après avoir fait part de sa consternation devant des épidémies incessantes et hautement meurtrières au Yunnan, Cheng Hanzhang interroge cette divinité clairvoyante et sollicite le pardon, en des termes qui seront repris, une centaine d’années plus tard, par Zhou Ruzhao, alors sous-préfet de Jingdong : À mon humble avis, il doit y avoir une raison à la succession sans fin de ces calamités. Qu’on en voit une fois sur plusieurs années, ou une tous les mille ans… Mais je n’en ai jamais vu une qui soit si importante et si longue. Peut-être est-ce parce que moi, Yunnanais, ai commis des actions criminelles graves ? il n’y a pas de punition céleste qui ne soit la sanction des actions humaines. Il en est toujours ainsi. Le Seigneur d’en haut a un état d’esprit bienveillant et a la charge de pardonner les crimes. Je vous prie humblement de faire preuve de compassion, de me pardonner, de mettre fin à cette calamité que sont les épidémies, de répandre le bonheur de la paix et que les montagnes, les rivières, les herbes et les arbres reçoivent votre miséricorde31. Les réponses individuelles ou collectivement orchestrées par les autorités en place témoignent, jusque dans les premières années du XXe siècle, d’une conceptualisation démonologique de l’épidémie.

19 Certaines biographies de médecins témoignent en effet de l’assistance que ces derniers prêtent aux malades, en temps d’épidémies. C’est souvent sous la forme classique de distribution gratuite de remèdes, assistance généralement attendue du pouvoir impérial32, que l’aide médicale est décrite, mais pas seulement ; parallèlement à ces récits permettant au biographe de rappeler et valoriser une partie importante de l’éthique médicale, comme la compassion et la charité33, d’autres biographies suggèrent des soins personnels, des rencontres entre médecins et victimes de l’épidémie. Ces témoignages, certes indirects, nous invitent donc à regarder de plus près les discours que les médecins chinois du lieu, dans leur grande diversité, tiennent à l’égard du phénomène épidémique que la démonologie n’est donc pas seule à expliquer ni à juguler. La dimension collective de l’épidémie qui, en réponse, fait marcher ensemble la population dans un effort commun de rédemption, ne doit pas cependant faire oublier l’individu malade, auquel, peut-on penser, les médecins tentaient d’apporter soulagement, explications et conseils.

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L’épidémie : une entité médicale discrète qui divise les médecins

Des sources parcellaires : les textes médicaux localement produits et conservés

20 Le moyen essentiel d’accéder à la culture médicale des XVIIIe et XIXe siècles dans cette région consiste aujourd’hui à explorer la littérature médicale qui y a été produite et qui a survécu. L’examen des titres de livres médicaux écrits au Yunnan, au Guangxi et au Guangdong, au cours de la dernière dynastie (1644-1911), connus grâce aux recensements bibliographiques qui étaient régulièrement établis pour chaque division administrative de l’empire lors de la rédaction de sa chronique locale fait état d’un total de 158 titres pour la province du Guangdong, de 61 pour le Guangxi et de 50 pour le Yunnan34. Une vingtaine d’ouvrages seulement et principalement en provenance du Guangdong semble avoir survécu35. Ce constat invite à la prudence. Si, comme de nos jours, tous les médecins du Sud de la Chine n’ont pas consigné par écrit leur manière de comprendre les maladies et les patients qu’ils avaient sous leurs yeux, privant ainsi l’historien de traces écrites, même lorsque ceux-ci jugèrent important de le faire, peu sont parvenus à franchir les obstacles de l’histoire du livre et à les transmettre à la postérité36. La littérature médicale qui subsiste n’est donc qu’une infime partie de ce qui a été écrit ; les conceptualisations du phénomène épidémique qu’elle nous laisse entendre s’inscrivent dans une partition probablement plus complexe.

Des titres qui confirment la progression des épidémies dans le Grand Sud

21 Si les textes médicaux ont aujourd’hui en grande partie disparu, leurs titres nous sont connus. Certains évoquent la notion d’épidémie. À la fin de l’empire, les caractères yi, wen (radical de la maladie) ou l’association wenyi sont généralement utilisés dans les sources administratives pour désigner l’épidémie. Les shibing (« maladies saisonnières »), les wenbing (« maladies tièdes »), catégories nosologiques anciennes, peuvent aussi désigner des maladies épidémiques37.

22 C’est au Yunnan que les premiers textes en relation directe avec le concept de yi ou wenyi sont écrits (à la fin du XVIIIe siècle) et dans une proportion plus importante qu’ailleurs. Quatre livres écrits au Yunnan mentionnent le terme générique d’épidémie dans leur titre : le Recueil des maladies épidémiques (Wen yi ji yao), écrit à l’époque Jiaqing (1796-1821) par Li Benxiu ; un autre livre portant le même titre est attribué à Qian Maoling, reçu juren en 1798. Enfin, un certain Cao Hongju, originaire de Kunming, mais dont les dates nous sont inconnues, commenta deux textes traitant des épidémies : le Traité des maladies fébriles épidémiques (Wen yi lun de Wu Youxing, écrit en 1642) et l’Analyse des maladies épidémiques fébriles (Wen yi tiao bian probablement de Yang Xuan, ca 1784). Aucun livre écrit dans la province du Guangxi ne porte en son titre le terme générique d’épidémie, ni celui de « maladies tièdes ». Enfin, dans la littérature médicale du Guangdong, un seul livre, écrit à la toute fin du XIXe siècle, mentionne le caractère yi : il s’agit du Livre pour sauver des épidémies (Qiu yi quan sheng bian) de Liang Guoheng, écrit en 1899. Trois autres titres, contenant les caractères wen (radical de

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l’eau) ou wen (radical de la maladie), pouvant évoquer l’épidémie, sont écrits à la fin du XIXe siècle.

23 Si un doute demeure sur la nature de la maladie incriminée dans les phénomènes épidémiques du Sud de la Chine, le fait que les premiers textes explicitement consacrés aux épidémies dans ces trois provinces aient d’abord été écrits au Yunnan, et en plus grande quantité, confirme la chronologie et la spatialisation des épidémies reconstituées par les historiens à partir d’autres sources : parti du Yunnan à la fin du XVIIIe siècle, le mouvement épidémique gagne, au fil du XIXe siècle, les autres régions du Sud. Les titres mettent aussi en lumière une sorte d’actualisation des préoccupations médicales : c’est au Yunnan qui subit, en premier, l’offensive d’épidémies inédites que les médecins consacrent l’écriture d’un nouveau livre de médecine au phénomène épidémique. Il est toutefois impossible de l’affirmer car ces textes qui auraient pu, dans leur préface, notamment, fournir des informations sur la nouveauté ou l’ampleur d’un phénomène aussi spectaculaire que l’est une épidémie, font malheureusement partie de l’immense majorité des textes médicaux de ces régions qui ont aujourd’hui disparu.

24 Ce n’est donc pas les textes spécialement consacrés aux épidémies que nous avons pu interroger pour comprendre le sens que les médecins locaux, plus ou moins contemporains des épidémies, accordent à ce phénomène, mais la littérature médicale qui a survécu et qui compte des traités généraux de médecine, des œuvres spécialisées dans un domaine comme la pédiatrie, la science des yeux ou les « maladies de chaleur caniculaire » (shuzheng), ou encore des livres destinés à expliciter ou simplifier les classiques du passé. C’est un corpus d’une vingtaine d’ouvrages, écrits entre 1739 et 1933, provenant, pour deux d’entre eux, du Guangxi, les autres ayant été produits en différents points du Guangdong. Un seul texte médical du Yunnan semble avoir survécu dans les bibliothèques chinoises, inaccessible à ce jour38.

Épidémies et miasmes dans le regard médical du Grand Sud : un silence assourdissant

25 La lecture de ces textes frappe tout d’abord par l’absence, dans les préfaces, de discours sur la spécificité et la particulière insalubrité du Sud de la Chine. Cette absence a de quoi surprendre. Comme l’ont montré Gérard Genette et bien d’autres chercheurs spécialistes du paratexte, la préface a toujours pour fonction de valoriser une œuvre, auprès du lecteur, de l’éditeur ou du libraire39. La réputation d’extrême insalubrité du Sud de la Chine étant si largement partagée, les médecins auraient pu utiliser ces premières pages pour valoriser leur œuvre en la présentant comme le recueil indispensable de survie aux dangers spécifiques de la région. En fait, seulement deux préfaces signalent la spécificité des lieux : celle de Zhao Jinsheng, écrite à la fin du XIXe siècle, pour le livre de son père Zhao Zhibeng Soigner les miasmes (Zhi zhang du), livre aujourd’hui perdu mais dont la préface a été préservée dans la chronique de Longling, dans l’Ouest du Yunnan, et celle de Miao Fuzhao signée en 1823 pour un texte Nouvelles formules pour soigner les empoisonnements (Zhi gu xin fang) écrit par Lu Shunde, un lettré du Nord du Guangxi. La première souligne la grande mortalité qu’on rencontre à Longling : « Longling est une contrée miasmatique zhang. En été et en automne, les gens meurent des miasmes, seulement 6 ou 7 sur 10 survivent40. » La préface de Miao Fuzhao, un homme originaire du Jiangsu qui trouva le manuscrit des Nouvelles formules pour soigner les empoisonnements lors des nombreux déplacements qu’il fit entre le Jiangsu et

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le Sud de la Chine entre 1818 et 1834, souligne le caractère dangereux de la région par ses miasmes mais aussi ses « barbares » : « Pendant 17 ans, j’ai fait ce voyage plusieurs fois, traversant les Barbares et les pluies miasmatiques, étant chaque jour en grand danger41. » Ce préfacier qui vient donc d’une région plus centrale où, comme il l’écrit – « la population est saine et les ressources abondantes » –, puise vraisemblablement sa description du Grand Sud dans l’imaginaire lettré du centre qui craint les marges de l’empire aussi bien pour ses pathologies que pour ses populations non sinisées qui finissent par être associées dans une fantasmagorie redoutée42. À l’exception de ces deux préfaces, dont l’une provient d’un observateur étranger au Sud de la Chine, aucun auteur local n’inscrit son texte médical dans un enfer morbide spécifique, et tous préfèrent valoriser leur œuvre en reprenant les grands topos des préfaces des traités médicaux de l’époque : l’importance de la médecine et du médecin à égalité avec la culture classique et le bureaucrate, la maîtrise par l’auteur des nombreux textes classiques, l’effort de simplification et de clarté dans le propos ou encore la restauration des textes et idées authentiques du passé43.

26 Les sommaires ne révèlent pas non plus une situation alarmante. Aucune table des matières ne consacre d’entrée aux miasmes et très peu aux épidémies réservant leur titre de chapitre à des pathologies beaucoup plus classiques. Il arrive pourtant, au fil du propos, que certains auteurs mentionnent les wenyi (épidémies fébriles), les yi (épidémies), ou les shiyi (épidémies saisonnières) : c’est le cas de Liu Yuan en 1739, He Mengyao en 1751, Yu Tingju en 1780, Wang Xueyuan en 1838, Liang Lianfu en 1881 ou Cheng Zhenge en 1892 qui écrivent depuis des situations différentes, non seulement par la chronologie ou la localité mais aussi par l’absence ou la présence d’épidémies telles qu’on les connaît par d’autres sources. L’examen de leur discours permet de saisir le sens alors donné dans les milieux médicaux au phénomène épidémique.

L’épidémie à l’épreuve de la définition

27 Un trait caractérise l’ensemble de cette littérature médicale, que l’on explore celle du début du XVIIIe siècle ou celle de la fin du XIXe siècle, pourtant contemporaine d’épidémies que les lettrés chinois comme les observateurs européens signalent régulièrement : les termes utilisés traditionnellement pour désigner l’épidémie – yi (« épidémie »), wenyi (« épidémie fébrile »), wenbing (« maladie tièdes ») ou wenbing (« maladies fébriles ») (wen écrit avec le radical de l’eau est traduit par « tiède » ; wen portant le radical de la maladie est traduit par « fébrile », selon la distinction établie par Hanson 2011 : 1, note 3) – ne sont jamais associés à une surmortalité ni à une morbidité particulièrement sévère et n’offrent jamais l’occasion à un auteur d’insérer un récit de catastrophe humaine. Ceci a encore de quoi surprendre : quand Wu Youxing, un médecin de Suzhou, écrit en 1642 son Traité sur les épidémies fébriles (Wen yi lun), il évoque l’épidémie qui a fait des ravages en 1641 au , au Zhejiang, dans les régions actuelles de Pékin et Nankin, et la mortalité inédite qui l’accompagne44. Les caractères yi ou wenyi qu’un texte comme les Nouvelles méthodes de Danxi (Dan xi xin fa), au milieu du XVe siècle, définit comme la maladie que tout le monde attrape, ou plus proche de nos médecins, que la Compilation impériale du Miroir d’Or des lignages médicaux (Yu zuan Yi zong jin jian) interprète comme la maladie qui touche les vieux comme les enfants et par laquelle ils se contaminent mutuellement45, sont même parfois dissociés

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de la notion de maladie collective, comme ces différents médecins nous l’expliquent. Écoutons-les.

28 Liu Yuan est originaire de Canton et l’auteur d’une Compilation en médecine (Yi xue zuan yao, 1739). Il évoque les « épidémies tièdes wenyi » dans le second chapitre, consacré aux « Maladies par le froid et le vent », sous la forme d’une entrée : Maladies par le froid de type épidémie tiède wenyi lei shanghan : Le Classique dit : en hiver, si on est blessé par le froid, au printemps, ce sera une maladie tiède. Ces maladies tièdes sont donc dans la catégorie des maladies froides. La majorité se déclenche au printemps et en été parce que le Qi est chaud et humide, les pores de la peau ne sont pas resserrés, à un moment où l’on aime s’exposer au frais. On contracte alors un vent pathogène qui conduit le Yang à infuser à l’intérieur avant de se répandre ensuite partout. D’où une frilosité et une forte fièvre. Comme le Qi saisonnier s’écoule partout de la même façon, les gens semblent en être tous contaminés sui shiqi liuxing xie tong, yanruo chuanran. Naturellement, il y a une différence avec les maladies froides. Les maladies froides surviennent en hiver quand le climat est très froid, que les pores de la peau sont resserrés […]. Mais les épidémies chaudes surviennent au printemps et en été, quand le climat est doux et que les pores ne sont pas resserrés46.

29 Le titre même de l’entrée, la localisation du passage dans la structure générale de l’ouvrage et les arguments avancés situent l’auteur dans le contexte intellectuel de son époque : sans revendiquer une préférence pour un auteur particulier, Liu Yuan adopte les théories médicales de Zhang Zhongjing, auteur d’un Traité des maladies froides et des maladies combinées (Shang han za bing lun, IIe siècle de notre ère), largement diffusé au XIe siècle par le Gouvernement impérial des Song du Nord (960-1127)47. Dans ce traité, les « maladies froides », caractérisées, entre autres, par la présence chez le malade d’une forte chaleur ou fièvre, s’expliquait par l’invasion d’un froid ou d’un vent pathogène dans le corps par l’intermédiaire des pores de la peau. Ce froid pathogène entré généralement en hiver pouvait y rester sous une forme latente et déclencher une « maladie tiède » (wenbing) au printemps ou « chaude » (rebing) en été. Pour Zhang Zhongjing, les « maladies froides », « tièdes » ou « chaudes » relevaient donc du même agent pathogène, prélevé dans l’atmosphère régulière du cosmos, et appartenaient à une même catégorie de maladie ; seule la thérapie devait être adaptée, généralement échauffante pour les « maladies froides » et rafraîchissante pour les « maladies tièdes » et « chaudes », avec néanmoins de nombreuses subtilités en fonction de la progression de la maladie dans le corps, affectant en premier lieu les parties superficielles du corps, parcourues par les méridiens Yang, avant de s’infiltrer dans les parties profondes irriguées par les méridiens Yin48. Liu Yuan suit donc de très près ce maître antique, conseillant, pour les maladies froides, « l’éphèdre, la cannelle et autres substances piquantes et échauffantes pour disperser » et, pour les épidémies chaudes, « l’angélique et la buplèvre qui resserrent les pores ». Préconisant d’appliquer les principes thérapeutiques classiques (sudation, purge, réchauffement, refroidissement, tonification ou harmonisation) en fonction des formes spécifiques de la maladie (superficielle, profonde, froide, chaude, déficiente ou excessive), il conclut : « En somme, il faut les soigner comme les maladies froides. » Comme cet extrait le montre, Liu Yuan ne lie pas « l’épidémie tiède » à un phénomène de surmortalité ni à une morbidité exceptionnelle, même si la notion est associée à celle d’une maladie collective, expliquée ici par l’ubiquité du Qi saisonnier49. Liu Yuan fournit ici une explication configurationiste de l’épidémie, rattachant de façon intrinsèque le phénomène épidémique à l’environnement et à ses propriétés50.

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30 He Mengyao, titulaire du grade métropolitain, et écrivant son Marchepied pour la médecine (Yi bian, 1751) quelque vingt ans après Liu Yuan, réserve aussi une entrée aux « doctrines des maladies épidémiques fébriles (wenyibing lun) ». Cette discussion intervient dans son second chapitre, à la suite d’exposés sur les « maladies froides », de « chaleur caniculaire », « d’humidité », en bref, à la suite des catégories nosologiques classiques dont la cause est directement liée au Qi saisonnier. Cependant, le discours de He Mengyao est bien différent de celui de son aîné : Les maladies épidémiques fébriles (wenyibing) ne sont pas des maladies froides, les médecins d’aujourd’hui se trompent en croyant que ce sont des maladies froides. Les maladies froides s’attrapent par le Qi régulier du cosmos (shanghan gan tiandi de changqi), alors que dans ce cas, c’est le Qi putride du cosmos (ci gan tiandi de liqi)… Ce pathogène xie entre par la bouche et le nez ; il ne réside pas en profondeur, dans les organes ; il ne réside pas en superficie, dans les méridiens ; […] il est dans l’interstice entre la superficie et l’intérieur […]. Quand cette maladie débute, on a le froid en horreur, puis, tout de suite après, arrive la fièvre, ce n’est pas du tout comme dans les maladies froides où la fièvre est en même temps associée à une horreur du froid […]. Le pathogène n’est pas dans les méridiens, faire suer blesserait inutilement. On ne peut pas non plus purger, puisque le pathogène n’est pas en profondeur, donc la purge est sans intérêt51.

31 La cause, le point d’entrée, la spatialisation de l’élément pathogène et le développement de la maladie sont pour He Mengyao autant d’éléments qui différencient les « maladies épidémiques fébriles » des « maladies froides » et qui, en retour, appellent des thérapies distinctes. He Mengyao n’est pas le premier médecin à contester le savoir des anciens et, en l’occurrence, les doctrines de Zhang Zhongjing. Citant Yu Chang (1584-1664) qui reprit à son compte un certain nombre d’idées émises par Wu Youxing (Youke) dans son Traité sur les épidémiesfébriles (Wen yi lun, 1642), He Mengyao en réalité adhère à cette nouvelle épistémologie des maladies épidémiques qui identifie une étiologie et une physiopathologie distinctes de celles des « maladies froides ». Pour Wu Youxing, les « épidémies fébriles » (wenyi ou wenbing, radical de la maladie pour wen), comme les « maladies tièdes » (wenbing, radical de l’eau pour wen), moins sévères, sont causées par un Qi anormal, déviant, pestilentiel qui se distingue donc du Qi cosmique régulier à l’origine des « maladies froides ». Ce Qi pestilentiel entre dans le corps par la bouche ou le nez et ne progresse pas en suivant l’ordre physiologique des méridiens. Cette nouvelle conceptualisation des maladies épidémiques dut être accessible dans la province du Guangdong dès le début du XVIIIe siècle, grâce aux publications en 1724 et 1725 du livre de Wu Youxing ordonnées par le Gouverneur provincial du Guangdong52. He Mengyao, qui écrit son texte en 1751, adhère donc à cette nouvelle épistémologie des maladies épidémiques, élaborée sur le terreau d’un scepticisme croissant à l’égard des canons de l’Antiquité et d’une cosmologie toute puissante53. De façon surprenante, He Mengyao n’évoque dans ce chapitre définitoire ni la dimension collective possible de ces maladies ni la notion de contagion. C’est seulement dans la partie « formules thérapeutiques à l’usage des maladies épidémiques » qui suit l’exposé général que la notion de maladie collective apparaît, sans qu’elle soit explicitée ni qu’elle rende compte d’une catastrophe inédite. Deux items présentés de façon très laconique rapportent : « Tous les gens d’un canton ont attrapé un rhume et toussent, c’est aussi une épidémie (yi shi wen) : utiliser la poudre qui chasse le poison » et « dans un même canton, tous ont la fièvre et une chaleur interne : décoction pour chasser l’épidémie ». He Mengyao qui semble utiliser le concept de wenyi (« épidémies fébriles ») pour celui de wenbing (« maladies tièdes »),

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une possibilité offerte par Wu Youxing, semble aussi plus préoccupé à signaler les erreurs du passé et à prouver la véracité de cette nouvelle doctrine qu’à rendre compte d’épidémies spectaculaires.

32 Cette manière de comprendre l’épidémie est partagée et revendiquée par Yu Tingju, un homme originaire du Nord du Guangxi qui, dans ses Paroles Médicales du Cabinet Jintai (Jin tai yi hua, 1783), affirme : « Pour ce qui est des maladies épidémiques (wenyizheng), pendant longtemps nous n’avons pas eu de théorie sûre jusqu’à l’émergence de Wu Youke […] et de son livre le Wenyi lun […] Il faut le prendre pour maître quand on soigne une épidémie yizheng. » Comme He Mengyao, il partage le point de vue de Wu Youxing selon lequel la maladie entre par les narines ou la bouche, et critique ceux qui soignent les « épidémies fébriles » en se fiant aux principes des « maladies froides ». Mais à aucun moment il n’évoque la dimension collective de ce type de maladie54.

33 Liu Yuan, He Mengyao et Yu Tingju écrivent leurs traités dans les provinces du Guangdong et du Guangxi au fil du XVIIIe siècle ; selon la chronologie des épidémies établie sur la foi des sources administratives chinoises et des témoignages européens, ces auteurs sont encore à l’abri des épidémies récurrentes de peste ou de choléra. L’absence de notion de maladie collective ou le peu de relief qui lui est donné est peut- être liée à la situation épidémiologique dans laquelle ils vivent. Les textes qui suivent, écrits au fil du XIXe siècle, s’ils ne relatent aucune épidémie spectaculaire, évoquent plus régulièrement la dimension collective de ce type de maladie.

34 Dans un effort de synthèse, Wang Xueyuan, originaire de , dans la province du Guangdong, écrit en 1843 ses Principes pour les maladies de chaleur caniculaire (Shuzheng zhinan). Dans cet ouvrage qui n’est pas découpé en chapitres, il évoque l’épidémie (yi), à la suite d’une discussion sur les cinq manières dont peuvent se combiner, cosmologie à l’appui, les éléments climatiques (vent, chaleur, chaleur caniculaire, humidité, froid) au cours de l’été et provoquer des symptômes particuliers. Wang écrit : « Un Qi anormal et contagieux qui se déclenche hors saison, on l’appelle le Qi épidémique (tianxing buzheng zhi qi, fa feishi zhe yue yiqi). Et puis il y a aussi le Qi des maladies qui se transmet à d’autres (gengyou bingqi xiang chuanran). De porte en porte, tout le monde est malade. Ce sont les maladies épidémiques humaines, elles provoquent le plus de dégât hai55. » Un Qi anormal ou le Qi des maladies ou des malades sont pour Wang Xueyuan les deux causes des épidémies, qu’il est le premier de ces auteurs à signaler comme un phénomène collectif occasionnant le plus de dégâts parmi les hommes.

35 Liang Lianfu, originaire de l’actuelle ville de Nanning, dans le Guangxi, dans le premier chapitre consacré aux maladies de vent, de froid, de chaleur caniculaire, de son livre Ce qu’un ignorant en médecine doit savoir (Bu zhi yi bi yao, 1880), réserve aussi une entrée aux « épidémies saisonnières » (shiyi) : reprenant l’idée alors couramment admise que ce type de maladie est causé par un Qi anormal, il introduit une distinction entre des épidémies liées à l’environnement et des épidémies liées à l’homme. Pour lui, ces deux formes ne présentent ni les mêmes symptômes ni la même propension à se répandre : Les épidémies saisonnières : ces syndromes, on les attrape par un Qi qui n’est pas normal (you buzheng zhi qi er de zhe). Céphalées, fièvres ou nuque enflée, infection suppurante des joues, tout ceci, c’est la maladie épidémique céleste/naturelle (ci zai tian zhi yi). Quand la maladie d’un homme se propage à la maisonnée, que de la maisonnée elle s’étend au canton, et que du canton elle se transmet à la ville, et que ce syndrome s’accompagne de froid, d’une forte fièvre, de vomissement d’un liquide jaune, alors c’est une maladie épidémique humaine (ci ren zhi yi)56.

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36 Enfin, le dernier auteur à évoquer le concept d’épidémie dans ce corpus de textes est Cheng Zhen’ge, originaire de Xinhui, au sud de Canton. Petit-fils de Cheng Binchen qui eut en main la nouvelle carte anatomique dessinée par Wang Qingren (1768-1831), il prend part aux dissections menées dans un hôpital anglais de Singapour, à la fin des années 1880. Dans son ouvrage Pivot des trames médicales (Yi gang cong shu, 1892), il réserve une entrée spécifique aux « épidémies fébriles » (wenyi), dans un chapitre relatif aux maladies qui « s’attrapent de l’extérieur » (waigan). Ce texte, en grande partie traduit ci-dessous, reflète l’imbrication de concepts empruntés aux médecines chinoise et occidentale (système respiratoire, système sanguin) mais aussi de pratiques d’observation (autopsie) pour définir l’épidémie : Les syndromes épidémiques se transmettent de porte en porte. Petits, ils ne touchent qu’un quartier ; grands, ils touchent plusieurs provinces. Ces maladies contagieuses proviennent d’un Qi empoisonné (duqi) qui est anormal. Il y a trois raisons à ce Qi empoisonné. Premièrement, les quatre saisons ne sont pas régulières, le froid et le chaud sont anarchiques, ils provoquent un Qi impur (zhuozhiqi) qui monte du sol et qui affecte les hommes. Deuxièmement, les égouts sont bouchés, les habitations sont malpropres, le Qi de ces impuretés et pollutions (huiwu duwu zhiqi) affecte les hommes. Enfin, la chaleur caniculaire est extrême, en se répandant sur le sol, elle provoque un Qi de poison humide qui affecte les hommes. Ces Qi empoisonnés suivent le vent et se répandent partout. Ce Qi rend malade. Si la personne ne mange pas de façon équilibrée, ou si son sang et son Qi ne sont pas en harmonie, à son contact, le Qi empoisonné entre par la bouche et le nez dans le système respiratoire (xiguan) ; de là, il passe dans le système sanguin (xueguan) et quand le système sanguin a reçu la maladie, elle envahit la couche de campement (ying) et endommage la couche défensive (wei), et alors la Désorganisation soudaine (huoluan) peut se déclencher. On les appelle les maladies chaudes épidémiques, elles font le lien entre le ciel et l’homme… Quand il (le Qi épidémique) envahit le haut (du corps), la tête et les yeux sont pris de vertiges, quand il envahit le bas, les intestins et l’estomac sont pris de vomissements et de diarrhées intarissables, il gagne les muscles et la couche défensive, au point que les muscles se contractent en spasmes. Le ventre et l’abdomen sont très douloureux. Il finit par envahir l’ensemble du corps, alors il y a rétraction des yeux, des oreilles, du nez, de la langue, chez les hommes rétraction du pénis, chez les femmes, rétraction de la poitrine et des organes génitaux. La circulation sanguine est mise sous pression en surface, le sang ne circule plus, alors les doigts et les ongles deviennent violacés. En profondeur, il attaque les organes (zang et fu) et consume la force vitale au point que les tissus des organes se rétractent. Pour ce syndrome il n’y a qu’à disperser très vite le Qi vital. On peut en mourir au bout d’une heure ou deux, ou au bout de 2 ou 3 jours. Personnellement j’ai été dans les hôpitaux, et j’ai pratiqué la dissection sur plusieurs morts d’épidémie (yisi) et j’ai vu dans les intestins et l’estomac beaucoup de liquide blanc. La peau à l’intérieur était devenue blanche ; les canaux sanguins étaient pleins de sang mais noir. Le gros intestin et la vessie contenaient peu de chose. L’intérieur des organes abritait du sang noir, c’est ainsi qu’on sait qu’ils avaient attrapé cette maladie57.

37 Ce qui, pour Cheng, définit l’épidémie, c’est la contagiosité, une contagiosité pouvant affecter plusieurs provinces. Comme nombre de ses contemporains, il lie la contagiosité des maladies épidémiques aux qi impurs portés par le vent, mais à la liste classique des éléments en cause – l’irrégularité des saisons, les phénomènes climatiques paroxystiques –, il ajoute l’obstruction des égouts et l’encombrement de la voirie et des habitations, dans un discours très proche de celui que les médecins européens tiennent alors à l’égard de la Chine et qu’il a probablement entendu et qui fait aussi écho aux explications de Chen Yan (XIIe siècle)58. Mais Cheng est plus précis que ses

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prédécesseurs, l’épidémie c’est le huoluan. Ce terme, employé depuis les premiers textes de médecine, pour désigner un ensemble de syndromes digestifs brutaux incluant toutes sortes de symptômes dont une diarrhée et des vomissements intempestifs, est aussi le terme retenu pour désigner au XIXe siècle le véritable choléra. Les signes cliniques que Cheng ici lui associe – vomissements et diarrhées incoercibles, douleurs dans l’abdomen, doigts et ongles violacés, mort en quelques heures ou quelques jours – laissent penser au choléra. Pour Cheng, le choléra est le paradigme de l’épidémie et non la peste qui, en 1892, a déjà provoqué des épidémies dans la province mais n’est pas encore aussi visible que ne l’est le choléra.

38 Comme ces extraits le montrent, aucun des textes médicaux du Sud de la Chine qui ont survécu ne rapporte d’événements pathologiques collectifs dramatiques en relation avec le terme d’épidémie. On peut aller plus loin ; aucun phénomène de surmortalité ou de surmorbidité n’est signalé dans ces textes, y compris lorsque les auteurs abordent des entités comme le huoluan, qui recouvre donc au XIXe siècle une large palette de syndromes, dont le véritable choléra, pourtant hautement contagieux. Ceci a encore de quoi surprendre : quand Wang Shixiong écrit en 1838 son Traité sur le choléra (Huoluan lun), lui et ses préfaciers mentionnent, à plusieurs reprises, combien la maladie est nouvelle, combien elle est partagée et mortifère59. Si la quasi-totalité des auteurs du Grand Sud évoquent au sujet du huoluan des formes sévères et foudroyantes pouvant amener la mort rapidement, à la suite de crampes du mollet, de la rétraction de la langue, et des doigts et ongles violacés, autant de symptômes révélateurs du véritable choléra, aucun n’associe cette forme de maladie à un phénomène collectif de grande ampleur. Il y a donc dans le chœur médical du Grand Sud, en petite partie réunie ici du fait d’une très grande perte dans la transmission des sources, un silence sur l’étendue des désastres générés par les épidémies, qui contraste singulièrement avec la ritournelle des morts innombrables entonnée par les lettrés dans les chroniques locales ou par les observateurs, parfois médecins, extérieurs au lieu60. Si deux auteurs signalent, l’un, en 1843 – et possiblement lié au fait de la diffusion au début du XIXe siècle du choléra en Chine –, que des dégâts peuvent être importants pour les hommes et, l’autre, à la toute fin du XIXe siècle, qu’une épidémie peut se diffuser sur plusieurs provinces, aucun des textes médicaux du Grand Sud ne rapporte d’exemples précis de ces phénomènes.

Les facteurs explicatifs et les mécanismes de la maladie collective

39 Dans ce chœur, plusieurs voix se font néanmoins entendre pour expliquer la dimension collective d’une maladie, à l’endroit des yi ou wenyi, on l’a vu, mais ailleurs aussi. Ainsi He Mengyao, dans son exposé sur les épidémies, ne mentionne pas la dimension collective des maladies, mais il l’évoque à l’occasion des « maladies de consomption xujuan laozhai61 ». Huang Yan ou Pan Mingxiong, deux auteurs du Guangdong écrivant dans la seconde partie du XIXe siècle, ne traitent pas d’épidémies au sens large mais rapportent néanmoins la contagiosité de certaines maladies comme la « Maladie externe de l’œil rouge » (chi yan waizhang) ou le li qui traduit aujourd’hui la « dysenterie62 ». Il est temps de réunir ces voix et d’en dégager la tonalité générale avec ses dièses et ses bémols.

40 Si Liu Yuan attribue la cause de ces maladies collectives à un Qi normal, saisonnier ou cosmique, suivant en cela la théorie classique des « maladies froides » de Zhang

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Zhongjing, la majorité des médecins du Grand Sud des XVIIIe et XIXe siècles invoquent des Qi anormaux (buzheng), impurs (zhuoqi), empoisonnés (duqi), immondes (huiwu duwu zhiqi, huiqi), pestilentiels (liqi). Pour eux, les maladies de nature épidémique ne cadrent pas avec l’orthodoxie configurationiste, largement diffusée sous les Song du Nord et mettant en cause un Qi saisonnier excessif ou un Qi décalé par rapport au cycle cosmique des années63. Ils adhèrent bien davantage à la conception étiologique nouvelle de ces maladies, systématisée par Wu Youxing en 1642, largement diffusée dès la fin du XVIIe siècle et très favorablement accueillie par l’élite médicale de l’époque, celle du Jiangnan64. Pour la majorité des auteurs du Grand Sud dont les textes ont été préservés, l’épidémie est donc la conséquence d’un Qi putride ou immonde porté par le vent ou plus généralement par l’air qui entoure l’homme et qui circule (xing), comme l’association fréquente des termes tianxing ou shixing (circulation céleste ou saisonnière) en témoigne.

41 Néanmoins, le terme de « contamination » (chuanran) est également utilisé dans ces extraits, parfois même défini en rapport avec la notion de contact entre humains. Pour Wang Xueyuan, on l’a vu, c’est en partie le Qi des malades ou des maladies qui contamine les voisins. Cette contagion interhumaine s’explique aussi par le vieux truchement d’une vermine diabolique s’échappant des cadavres : « Quand la consomption dure depuis longtemps », écrit He Mengyao, « cela peut engendrer de la vermine (echong) qui ronge les viscères et les entrailles. […] Quand le corps est mort, elle se transmet aux enfants et petits-enfants ; dans les cas extrêmes, elle peut anéantir une famille ; on l’appelle la consomption contagieuse par le cadavre (chuanran zisun, shen er miemen, mingyue chuanshilao) ». Comme le rappelle Angela Leung, cette contagion intrafamiliale des maladies de consomption par l’intermédiaire du cadavre est connue depuis le VIIIe siècle. Elle est intimement liée aux idées bouddhiques et taoïstes de la maladie, perçue comme la conséquence des fautes d’un individu pouvant sanctionner tous les membres de la famille65. L’explication que He Mengyao rapporte – « les vers des cadavres de consomption, ce sont des Qi démoniaques (guiqi). Ils sont latents et pas encore éveillés, dès que le corps est décharné, les Qi démoniaques s’envolent et se propagent dans l’entourage » – et la thérapeutique qu’il propose – moxas à appliquer à la deuxième veille de la nuit d’un jour guihai, utilisation de substances comme l’arsenic qui aident à expulser le néfaste (quxie), ou de dents de tigre ou de squelette d’une tête de carpe « car ce sont précisément des êtres qui mangent les hommes et que les démons redoutent », l’absorption d’un talisman au Boisseau du Nord, qui inclut le bureau des exorcismes – inscrit sa conception de la contagion interhumaine dans la dimension fortement démonologique de la médecine des Sui (589-618) et des Tang (618-907), telle qu’on la connaît au travers de ses œuvres maîtresses66.

42 Cette conceptualisation ancienne de la contagion interhumaine qui, par la suite, a été étendue à d’autres types de maladie comme la lèpre, est partagée par Huang Yuanji, un contemporain de He Mengyao ; elle est néanmoins rarement signalée dans ces textes, quand certains auteurs, presque contemporains, comme Lu Shunde et Miao Fuzhao, réfutent l’idée même d’une contagion interhumaine. Traitant de ce qui semble désigner la lèpre, ces auteurs, qui paraissent redouter les conséquences immorales de la doctrine contagioniste, comme l’abandon des malades par la famille, récusent l’idée d’une contagion possible entre les membres d’une même maison et mettent en garde leurs lecteurs : Il ne faut pas avoir peur… Le gangu peut toucher une ou deux personnes, ou trois ou cinq. Ils peuvent être au même endroit et recevoir ce poison. Ou alors ils peuvent

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être à des endroits différents et recevoir ce poison… Les gens s’imaginent que c’est contagieux (chuanran), c’est quelque chose qu’on ne doit pas croire67.

43 Enfin, certains auteurs prônent une synthèse des mécanismes explicatifs alors en vigueur. Ainsi, Pan Mingxiong, pour expliquer la diffusion des maladies li (« dysenteries »), réunit l’approche classique, configurationiste, du Qi saisonnier et cosmique et celle, contagioniste, introduite au XVIIe siècle par Wu Youxing. En fait, la dysenterie (lizheng) peut être saisonnière (shixing) ou contagieuse (chuanran), il y a les deux sortes qu’il faut bien différencier : la saisonnière entre par la peau et les poils. On voit une crainte légère du froid. Quand le vent chargé de pathogène passe sur une famille, toute la famille est malade, [quand il passe] sur un canton, tout le canton est malade… La contagieuse entre par le nez et la bouche, on n’y voit pas la crainte du froid ; elle résulte d’un contact avec un Qi pollué (huiqi). Quand il touche (ran) une personne, celle-ci tombe malade, s’il touche un quartier, le quartier est malade68.

44 Si les phénomènes épidémiques ne sont jamais débattus dans ces textes médicaux dans une mise en scène pathétique, ils donnent lieu à des réflexions sur les manières dont ils sont compris et combattus. L’examen de ces extraits nous met en présence d’une polyphonie qui n’est pas sans rappeler celle qui se fait entendre dans l’Europe du XIXe siècle pour expliquer l’épidémie : les tenants du configurationisme, en minorité ici, coexistent avec les tenants du contagionisme, mettant le plus souvent en cause des Qi pollués portés par les airs, heurtant les hommes, mais aussi l’homme, soit par le Qi de sa maladie soit par ses émanations diaboliques.

45 Pour ces médecins, le combat à mener est le même que pour n’importe quelle autre maladie : à l’exception de He Mengyao qui, dans le cas précis des consomptions contagieuses, prône une médication largement inspirée par une conceptualisation démonologique de la contagion, tous adoptent une stratégie médicale : ils prescrivent des remèdes, recommandent l’abstention de certains mets et, dans les cas sévères, notamment en liaison avec l’entité « Désorganisation soudaine » (huoluan), la ponction dans la perspective d’évacuer le sang corrompu. Il pourrait paraître surprenant, face à l’essor que prend la doctrine médicale de l’épidémie comme résultant d’un Qi immonde pénétrant l’homme par le biais des narines ou de la bouche, qu’une prévention contre l’intrusion de ce Qi particulier ne soit pas mise en avant par ces médecins. En fait, ce qui semble garantir la meilleure des préventions, c’est la conduite responsable de l’individu. Manger correctement et avoir son Qi et son sang équilibrés sont pour Cheng Zhen’ge les manières d’éviter l’intrusion du Qi pathogène. C’était en des termes proches que Jin Gui, un éminent lettré du XVIe siècle, dans une critique sévère à l’égard de ceux qui accusaient le Grand Sud d’être dangereux pour ses miasmes, garantissait l’immunité. Pour l’un de ses élèves, reçu aux concours impériaux et nommé dans la sous-préfecture de Guixian, au Guangxi, il écrivit un texte lui recommandant une conduite morale irréprochable susceptible de lui apporter la meilleure des prophylaxies : Si notre Qi originel n’est pas comble alors le Qi extérieur en profite pour envahir. […] Celui qui fait cas de sa vie est vigilant, il se met des limites aux passions qui sont sans limites ; il se surveille quand bien même les manières de vivre ne lui sont pas imposées. Son Qi originel se fortifie et le xie externe ne l’atteint pas69.

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Conclusion

46 Les pratiques que les épidémies suscitent dans la société chinoise de la fin de l’empire et les discours qui sont écrits à leur endroit dans les sources historiques ou dans les textes médicaux permettent d’esquisser une carte des savoirs et des imaginaires qui leur sont liés. Sans surprise, ces différents témoignages rendent compte d’une multiplicité de significations. Au même titre que les invasions de sauterelles ou les inondations, les épidémies sont des anomalies qui doivent être consignées pour les besoins de l’administration et de la connaissance historique. Mais les épidémies ne sont pas des réalités historiques imprévisibles et inexplicables. Au cœur de pratiques religieuses qui perdureront bien après la mise en place de politiques de santé inspirées par une médecine scientifique, l’épidémie est, à la fin de l’empire, encore largement associée à l’idée de punition collective infligée par une divinité courroucée. L’ordre divin requis pour expliquer le phénomène épidémique est toutefois concurrencé par un ordre naturel qui ne s’explique pas d’une seule et même voix. Ici comme ailleurs, en l’absence d’un cursus médical uniforme, la menace épidémique s’explique en des termes distincts : les irrégularités du cycle cosmique ou les putréfactions environnementales engendrent des Qi anormaux ou immondes qui, par leur ubiquité, parviennent à toucher la collectivité. S’insinuant tantôt par la peau, selon la doctrine classique des maladies froides, pénétrant tantôt par la bouche ou le nez, selon les théories de Wu Youxing, la maladie épidémique, dans cet espace-temps, ne s’explique pas autrement qu’en s’appuyant sur les modèles étiologiques et physiopathologiques dominants de l’époque, à savoir ceux qui s’élaborent par les médecins du Jiangnan et dont les auteurs du Grand Sud sont de fervents lecteurs70.

47 La confrontation de ces divers témoignages illustre également un écart surprenant entre les manières de se représenter le Grand Sud. Enfer morbide pour les lettrés qui doivent s’y rendre ou pour ceux qui consignent les anomalies historiques, enfer également pour les médecins extérieurs à la région qui l’accusent d’être la source de maux étrangers et inconnus71, le Grand Sud est au contraire terre de normalité pour les médecins du lieu. Si l’idée qu’une maladie puisse se propager dans une famille, dans un canton, dans une province est émise dans quelques rares textes médicaux, la maladie contagieuse amenant à des épidémies mémorables n’est pas la caractéristique du territoire. On ne peut qu’émettre des hypothèses sur cet écart des représentations. Les épidémies ne sont pas peut-être pas si visibles en cette fin du XVIIIe et tout au long du XIXe pour retenir l’attention de tous les médecins ; elles sont peut-être aussi trop récentes pour être débattues dans des textes théoriques ; c’est peut-être aussi la vocation du texte médical – apprendre à soigner les autres et à se soigner – qui pousse les auteurs à s’intéresser davantage à l’individualité de la maladie qu’à la dimension collective de celle-ci. On peut enfin suspecter la volonté chez ces auteurs de rattacher le Grand Sud, considéré comme géographiquement et culturellement périphérique, à l’univers moins exotique de la Chine centrale en en gommant les anomalies légendaires. Et en effet, si les épidémies ou les miasmes du Sud de la Chine n’ont que peu d’écho dans ces textes médicaux, c’est plus largement la spécificité des lieux qui est passée sous silence. Quelques auteurs signalent bien une singularité de la pathocénose de l’extrême Sud : Huang Yuanji à la fin du XVIIIe siècle signale qu’au Lingnan il y a le taoshengdu, synonyme du gu (« empoisonnements »), souvent associés aux pratiques de magie noire dont sont accusées les ethnies non sinisées du Grand Sud72 ; He Mengyao,

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recopiant un passage de la Collection Générale Médicale de la Bienveillance Royale (sheng ji zong lu, ca 1117), rapporte un plus grand nombre de cas de jiaoqi (« flaccidité des pieds, possiblement béribéri) ») au Guangdong ; Wang Xueyuan, au début du XIXe siècle, admet qu’au sud du fleuve Yangzi, le climat est chaud, et tout particulièrement dans la province du Guangdong qui compte de ce fait un grand nombre de maladies de chaleur caniculaire en été73. Hormis ces évocations, rares et souvent reprises de traités plus anciens, la majorité des auteurs du Grand Sud dépeint la pathocénose du lieu dans les mêmes termes que leurs éminents collègues du Jiangnan. Certains, comme Chen Huangtang, défenseurs des doctrines de Zhang Zhongjing, dénient toute spécificité pathologique ou corporelle aux régions de la Chine : « Les hommes ont tous les mêmes os, les mêmes articulations, la même chair, par conséquent les maladies qu’ils attrapent sont identiques74. » D’autres, comme Yu Tingju, se rangent du côté des contestataires de cette tradition qui, au fil des XVe, XVIe et XVIIe siècle, au Jiangnan, soulignent au contraire la prévalence des maladies froides au nord et celle des maladies tièdes et chaudes au sud, où, de surcroît, les corps sont plus frêles et ne répondent pas aux mêmes thérapeutiques75. Quelles que soient leurs préférences théoriques, ces auteurs du Grand Sud ne dépeignent pas l’Extrême Sud de la Chine comme ce lieu pathologiquement exotique si souvent décrit76. Pas d’épidémies particulières dans le Grand Sud, ni même de maladies étranges, mais un paysage médical et humain qui peut se comprendre soit par le prisme de la tradition des Han, celle de Zhang Zhongjing, soit par celle qui la conteste depuis la fin des Ming, avec notamment Wu Youxing, mais qui est tout aussi légitime car produite depuis le centre culturel du Jiangnan.

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ANNEXES

Glossaire baihou 白喉 Beihai 北海 bingyi 病疫 buzheng 不正 Cao Hongju 曹鴻舉 Cheng Hanzhang 程含章 Chenghuangshen 城隍神 chi yan waizhang 赤眼外障 chuanran zisun, shen er miemen, mingyue chuanshilao 傳染子孫, 甚而滅門,名曰傳屍 勞 chuanran 傳染 ci gan tiandi de liqi 此感天地的厲氣 ci ren zhi yi 此人之疫 ci zai tian zhi yi 此在天之疫 Dali 大理 datou wenzheng 大頭瘟症 duqi 毒氣 echong 惡蟲 fengre shidu 風熱時毒 fengsu 風俗 gangu 疳蠱 Gejiu 個舊 gengyou bingqi xiangchuanran 更有病氣相傳染 gu 蠱 guihai 癸亥 guiqi 鬼氣 hai 害 Haikou 海口 Hainan 海南 He Yu 何瑜

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Huang Tingju 黄廷矩 Huiqi 穢氣 huiwu duwu zhiqi 穢污毒物之氣 huoluan 霍亂 jiaoqi 腳氣 Jin Gui 靳貴 Jingdong 景東 juren 舉人 Leizhou 雷州 Li Benxiu 李本修 Li Runguang 李潤光 Liang Guoheng 梁国珩 Lingnan 嶺南 liqi 癘氣 lizheng 痢癥 li 痢 Longling 龍陵 Maoming 茂名 Pan Zhilian 潘之連 ping an jiao 平安醮 Potou 坡頭 qi maoding 起毛疔 Qian Maoling 錢懋龄 qing jiao 清醮 Qiu yi qu an sheng bian 救疫全生篇 qi 氣 qu yili 驅疫癘 quxie 驅邪 ran 染 rebing 熱病 shanghan gan tiandi de changqi 傷寒感天地的常氣 Shang han za bing Lun 傷寒雜病論 shanghan 傷寒 sheng yangzi 生痒子 shixing 時行 shiyi 時疫 shouzu mamu buren 手足麻木而不仁 shuzheng 暑症 sizhe wusuan 死者無算 sui shiqi liuxing jie tong, yanruo chuanran 雖時氣流行皆同。 儼若傳染 Taiping 太平 Tao sheng du 桃生毒 tianxing buzheng zhi qi, fazuo feishi zhe yue yiqi 天行不正之氣，發作非時者曰疫氣 toumian hunkuang er zuore 頭面昏況而作熱 tu hongxue 吐紅血 waigan 外感 Wangye 王爺 Wei 衛

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wenbing 溫病 wenbing 瘟病 wenbu 瘟部 wenshen 瘟神 Wen yi ji yao 瘟疫集要 Wen yi lei shanghan 溫疫類傷寒 Wen yi tiao bian 瘟疫條辨 Wen yi bing lun 瘟疫病論 Wen yi lun 瘟疫論 Wenyizheng 瘟疫症 wenyi 瘟疫 wu 巫 Wu Youxing 吳有性 Wudi 五帝 wuwen shezhe 五瘟使者 Xiangshan 香山 Xie Wenhui 謝文徽 xie 邪 xieli 瀉痢 xiguan 息管 xing 行 xinzheng 新政 Xu Gaoyi 許高儀 xueguan 血管 xujuan laozhai 虛捐癆瘵 Yao Wenzao 姚文藻 yi shi wen 亦是瘟 yigui 疫鬼 ying 營 yisi 疫死 yizheng 疫症 yi 疫 you buzheng zhi qi er de zhe 由不正之氣而得者 Yu Chang 喻昌 Yuhuang 玉皇 Zangfu 臟腑 Zhao Zhibeng 趙之琫 Zhao Jinsheng 趙金聲 Zhang Yingkui 張應奎 Zhang Zhongjing 張仲景 zhang 瘴 Zhi zhang du 治瘴毒 Zhou Ruzhao 周汝釗 Zhuo (zhi) qi 濁(之)氣 zu zhuanjin 足轉筋

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NOTES

1. Gong 1983 ; Benedict 1993 ; Bretelle-Establet 2002 : 154-160 ; Gabbiani 2011. Établi en 1905, le ministère de la Police, inspiré des modèles allemands et japonais, est doté d’un département d’hygiène chargé des questions de santé publique. Dans la première décennie du xxe siècle, quelques gouverneurs provinciaux mettent en place ces nouvelles institutions chargées notamment d’améliorer la voirie, de consigner les causes de mortalité et les cas de maladies contagieuses. Un service de prévention contre les épidémies est fondé en 1911. 2. Des épidémies anormalement rapprochées sont rapportées aux viie et viiie siècles, entre le xiie et xive siècle et au xviie siècle. Wu 1936 ; Dunstan 1975 ; Benedict 1996 ; Chen (n. d.). Sur l’histoire des réponses politiques apportées à ces crises et des changements épistémologiques, cf. Leung 1987 ; Hinrichs 2013 : 97-127 ; Benedict 1996 ; Hanson 2011. 3. Sur l’histoire, la distribution, les différents sens du zhang, cf. Hanson 2011 : 69-80 ; Bello 2005 ; Mou & Wang 2003. 4. Jingdong xianzhi 1923 : 1065-1068. 5. Guo 1987 : 2242. 6. Sur l’histoire et la composition des chroniques locales fangzhi, cf. Will 1992. 7. Benedict 1996 : 19, 20, 41, 42, 44, 46, 47, 61, 64, 66, 69 ; Xian 1988. 8. Mouvement politique et religieux réprimé par les troupes impériales en 1864 mais suivi de révoltes locales au Guangxi jusqu’à la fin des années 1870. Laffey 1976. 9. Xiangshan xianzhi, xubian 1923 : j.14, 6-7 et Guo 1987 : 2025. 10. Guo 1987 : 1979-1980, 1982 et Foshan zhongyi xiangzhi 1926, 14, 8 : 16. 11. Guo 1987 : 1985-1986. 12. Pour une chronologie détaillée des épidémies dans le Sud de la Chine et pour les références aux dossiers d’archives qui les signalent, cf. Bretelle-Establet 1999 : 166-193 et 2002 : 47-54. Sur la peste, cf. Xian 1988 ; sur le choléra, cf. Dudgeon 1877 : 44-45 et MacPherson 1998 : 487-519. 13. On trouvera différents types de réponses pour le monde européen et l’empire ottoman dans les travaux suivants : Panzac 1985 ; Brossollet et Mollaret 1994 ; Ruffie et Sournia 1984 ; Bourdelais et al. 1988 ; Pour l’iconographie de la peste à Marseille, cf : recueil. mmsh.univ-aix.fr/ htmlbertrand/winbertrand.html. Et sur l’essor d’une législation en Europe, voir Foucault 1975 : 228-233 ; Defoe 1721 ; Delaporte 1990. 14. GGI. dos.18319, 1902. 15. Pouthiou-Lavielle 1910 ; GGI. dos.40934, 1930. 16. Sur ce ministère, cf. Doré 1915 : 811-821 et Maspero 1971 : 195-197. 17. Sur ces divinités (cf. Doré 1915 : 811-821), appelées les Cinq Empereurs wudi au Zhejiang, cf. Katz 1995 ; Szonyi 1997. 18. Katz 1995 : 55. 19. Schipper 1985 ; Katz 1995 : 77-174. 20. Broquet 1902 : 8-11. 21. Le Dantec 1911. 22. Katz 1995 ; Bodde 1975. 23. Pour ce ritual au Guizhou, Benedict 1996 : 117. Pour le Guangxi, cf. Luchuan xianzhi 1924 : 78 ou Yulin zhouzhi 1895 : 69. 24. Lo 1929 : 6. 25. Liujiang xianzhi 1937 : 34. 26. Hsü 1955. 27. Sournia 1992 : 249-254 ; Guillaume 1996 ; Fee & Porter 1992. 28. GGI. dos.22003, 1894 ; Pouthiou-Lavielle 1910. 29. GGI. dos.22003, 1894 et GGI. dos.18319, 1902. Sur cette pratique, cf. Maspero 1971 : 195-196. 30. Maspero 1971 : 121-127 ; Johnson 1985 ; Ch’ü 1962 : 164-167 ; Cohen 1978.

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31. Jingdong xianzhi 1923 : 1065-1070. 32. Sur cette assistance « centrale », cf. Leung 1987 et Hinrichs 2013 : 97-128. Les biographies de Xu Gaoyi, Zhang Yingkui ou Pan Zhilian, entre autres, rapportent ce type de soutien, cf. Guo 1987 : 2242, 1983 et Zhongshan xianzhi 1933 : 169. 33. Sur l’éthique mise en avant dans ces biographies, cf. Bretelle-Establet 2009. On trouvera dans Guo 1987 : 2030, 2035, 2245, 2248 quelques-unes de ces biographies qui témoignent de l’activisme des médecins auprès des malades en temps d’épidémie. 34. On doit à Guo Aichun (1987) l’inventaire de ces titres. Fondé sur l’examen des bibliographies de centaines de chroniques locales par province, cet inventaire, qui n’est sûrement pas exhaustif, n’a cependant pas d’équivalent pour appréhender dans sa grande majorité la nature des œuvres médicales produites dans une localité particulière. 35. Selon le catalogue des fonds des bibliothèques chinoises de Xue 1991. D’autres textes ont peut-être survécu, ce catalogue n’est pas à l’abri d’erreurs ; par ailleurs des textes ont certainement été conservés au sein des familles et sont inaccessibles à l’historien. 36. Sur les différents facteurs pesant sur l’histoire du livre médical chinois, cf. Bretelle-Establet 2010. 37. Cf. Hanson 2011 pour une « biographie » du concept de « maladie tiède » (wenbing) par contraste puis, par opposition, à celui de « maladie froide » (shanghan). Pour une histoire et étymologie des termes relatifs aux maladies contagieuses, cf. Fan 1989 : 263-70. 38. On trouvera les titres de ces livres dans la bibliographie, sources primaires. 39. Genette 1987 et, pour d’autres références, cf. Bretelle-Establet 2011. 40. Longling xianzhi 1917 : 537. 41. Lu et Miao (1823) 1935 : 1. 42. Sur cette fantasmagorie associant Grand Sud, Barbares, miasmes, poisons, lèpre, cf. Hanson 2011, Bello 2005, Leung 2009, Obringer 1997. 43. Bretelle-Establet 2011. 44. Wu (1642) 2007 : 12. 45. Dan xi xin fa (1481) 2008 : 32 ; Wu (1742) 2006 : 823. 46. Liu (1739) 1873 : j2, 57a-b. 47. Sur l’histoire de ce traité dans le contexte plus large de l’histoire médicale sous les Song, cf. Goldschmidt 2009 et Hinrichs 2003. 48. Pour une traduction de ce traité en français, cf. Despeux 1985. 49. En vertu de la doctrine des « Cinq périodes et des six Qi wuyun liuqi », ajoutée au Canon Interne de l’Empereur Jaune, au viiie siècle, et largement admise sous les Song, le temps qui s’écoule, les caractéristiques climatiques du temps et les différents phénomènes naturels sont imbriqués dans un calendrier qui combine les influences Yin et Yang, les cinq phases wuxing et le système calendaire sexagésimal des « dix branches célestes » et des « douze rameaux terrestres ». Le Qi d’une saison n’est donc pas aléatoire mais prévisible et programmé par ce calendrier. Il se peut néanmoins qu’un Qi soit décalé par rapport à ce qu’il devrait être en fonction de ce système cosmologique et peut alors être source de maladie. Unschuld 2003 : 393-488 ou Despeux 2001. 50. Rosenberg 1992. 51. He [1751] 1994 : 128-134. 52. Hanson 2011 : 113. 53. Ce scepticisme qui commence à s’exprimer dans les textes médicaux sous les Song du Sud se radicalise et se théorise dans l’ouvrage de Wu Youxing. cf. Leung 2009 ; Hanson 2011. 54. Yu [1783] 1991 : 290. 55. Wang 1843 : 13. 56. Liang [1880] 1936 : 33. 57. Cheng 1892 : juan 2, 26.

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58. Leung 2002. 59. Wang 1838. 60. Sur la manière qu’ont certains médecins extérieurs au territoire, comme par exemple ceux du Jiangnan, de présenter le Grand Sud comme une région anormalement pathologique, cf. Hanson 2011 ; Leung 2009. 61. He [1751] 1994 : 193. 62. Huang 1879 : j5, 5 ; Pan [1865] 1868 : 14-15. 63. Cf. note 50. 64. Hanson 2011. Le Jiangnan (sud du fleuve Yangzi) est le nom donné à une partie de la Chine couvrant la majeure partie des provinces du Jiangsu, du Zhejiang et de l’. Région riche, abritant sous les Song du Sud, la capitale de l’empire, le Jiangnan est aussi un lieu de savoir qui, sous les deux dernières dynasties, se trouve au cœur de l’imprimerie commerciale, compte les plus grandes bibliothèques privées de l’empire et donne le plus grand nombre de lauréats aux concours métropolitains. Cette région est donc perçue comme un centre culturel majeur de la Chine sous les Ming et sous les Qing, vers lequel tous les yeux sont tournés, y compris pour la médecine. Cf. Elman [1984] 2001 : 178-208. 65. Sur l’influence taoïste de cette notion de contagion, cf. Leung 2010 : 25-50 et Strickmann 2002. 66. He [1751] 1994 : 193. cf. Leung 2010 : 25-50, pour un aperçu de cette notion chez Chao Yuanfang, Wang Tao et Sun Simiao. 67. Lu [1823] 1935 : 21. Sur l’association lèpre et vermine et sur les débats complexes autour de la notion de contagion, Cf. Leung 2009, 2010 et Hinrichs 2013 : 111-12. 68. Pan [1865] 1868 : 14-15. 69. Gui xianzhi 1935 : j.1, 65-66. 70. Sur les conceptualisations des épidémies au Jiangnan, cf. notamment Hanson 2011 : 107-150 et Leung 2009. Sur l’attractivité du Jiangnan comme centre culturel de référence pour ces auteurs du Grand Sud, cf. Bretelle-Establet, à paraître. 71. Comme les miasmes, la lèpre, la syphilis, cf. Leung 2009 : 45-51. Hanson 2011 : 69-90. 72. Obringer 1997. 73. Huang [1763] 1799, n. p., section « Formules pour sauver en urgence » ; He [1751 ?] 1918 : j. 4, 7; Wang 1843 : 17-18. 74. Chen 1849 : j1., 15. Yu [1783] 1991 : 287. 75. Hanson 2006 et 2011. 76. Hanson 2011 : 69-90.

RÉSUMÉS

Cet article esquisse la carte des savoirs et des pratiques qui sous-tendent la notion d’épidémie en Chine, à la veille de la mise en place d’institutions chargées de les surveiller, les contrôler et les combattre, sur la base des connaissances médicales, acquises au sein du laboratoire. Il prend comme cadre d’investigation l’extrême Sud de la Chine qui devint, à partir du XVIIIe siècle, le siège d’épidémies récurrentes rapportées par les observateurs chinois puis par les observateurs étrangers. En étudiant les initiatives individuelles ou politiquement orchestrées, en scrutant la

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littérature médicale contemporaine de ces vagues épidémiques et produite dans cet espace particulier, il met en lumière les manières dont les épidémies sont alors comprises et combattues.

This article sheds light on the different ideas and practices that surround the notion of epidemic in China before the implementation of institutions devoted to observe, contain and fight epidemics on the basis of laboratory medicine. It focuses on the Far South, which, in the last centuries of the empire, notably in the late eighteenth and nineteenth centuries, became the seat of epidemics reported by Chinese, and later, Western observers. By exploring the different discourses held on epidemics in this particular place and by analyzing the practical answers brought to these crises, this article sheds light on the different meanings attached to epidemics in late imperial China.

二十世紀初，清政府成立防疫局，建立各級防疫機構，開始採用西醫防疫措施，控制鼠疫和 其他傳染病的流行。根據清代地方志和當時西方人的報告，十八至十九世紀中國南方是疫病 頻仍的地區，尤其是邊遠的雲南、廣東和廣西等地。本文利用地方志、十九世紀西方人的報 告和地方醫學文獻，探討在西醫防疫措施被採用以前南方的防疫觀念和措施，並分析南方地 方社會大眾和醫生對疫病的反應和態度。本文最後透過疏理清末南方醫學界和地方社會大眾 對疫病的看法、解釋和爭論，剖析江南地區流行的疫病觀念對南方邊遠地區醫學界所產生的 影響。

AUTEUR

FLORENCE BRETELLE-ESTABLET Florence Bretelle-Establet is researcher in SPHERE team (UMR 7219, CNRS/Université Paris- Diderot). Since her PhD (1998), she has worked on the history of medicine in late imperial China. Author of La Santé en Chine du Sud. 1898-1928 (2002), she has published articles and book chapters on the history of medicine in the Far South of China and edited several books, notably Looking at It from Asia: The Processes that Shaped the Sources of History of Science (2010). With Romain Graziani, she is the chief editor of the journal Extrême-Orient, Extrême Occident. Florence Bretelle-Establet est chargée de recherche dans l’équipe SPHERE (UMR 7219, CNRS/ Université Paris-Diderot). Depuis sa thèse (1998), elle travaille sur l’histoire de la médecine en Chine, à la fin de l’empire. Auteure de La Santé en Chine du Sud. 1898-1928 (2002), elle a publié des articles et des chapitres de livre sur l’histoire de la médecine dans le Sud de la Chine et dirigé plusieurs livres, notamment Looking at It from Asia : The Processes that Shaped the Sources of History of Science (2010). Avec Romain Graziani, elle est rédactrice en chef de la revue Extrême- Orient Extrême-Occident.

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Jean-Jacques Matignon’s Legacy on Russian Plague Research in North- East China and Inner Asia (1898-1910) L’héritage de Jean-Jacques Matignon dans les recherches russes sur la peste dans le Nord-Est de la Chine et l’Asie centrale (1898-1910) 馬丁榮 (Jean-Jacques Matignon) 的鼠疫來源假說及其對俄國在中國東北 和內亞鼠疫研究(1898-1910) 的影響

Christos Lynteris

Research leading to this paper was conducted under an Andrew Mellon and Isaac Newton Interdisciplinary Postdoctoral Research Fellowship at the Centre for Research in the Arts, Social Sciences and Humanities (CRASSH) of the University of Cambridge and was also generously supported by a Cambridge Humanities Research Grant. I would like to thank the staff of the Russian State Library and Dr Valentina Kharitonova, director of the Medical Anthropology Group of the Institute of Ethnology and Anthropology of the Russian Academy of Sciences for their support during my research in Moscow.

1 Medical historical research on plague (Yersinia pestis) in Northeast China, or, to use the ethno-historically more relevant term, Manchuria, has witnessed a recent revival with many articles and one monograph published on the subject in the last ten years.1 All scholarly publications so far, including the ones by the author of this paper, have focused on the Manchurian plague epidemic of 1910-1911, a choice justified by the magnitude of the outbreak as a biopolitical and geopolitical event in the region. As a result, when it comes to examining perceptions of the cause of plague in Manchuria, historical research has focused on the zoonotic origins of the disease as propagated by Wu Liande, the leading Chinese epidemiologist at the time.2 However Wu’s writings on the subject were the final, and in many ways definitive, form of a long research trajectory that was initiated from across the Sino-Russian border in the 1890s. The zoonotic origin of plague in the region was problematised as early as 1894 in the work

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of Russian medical researchers operating in Transbaikalia.3 They argued that the main vector of plague was the Siberian marmot, or so-called tarbagan; a large rodent hunted by native Mongols and Buryats for its fat, fur and meat. The pioneer of these studies was Mikhail Edouardovich Beliavsky, a senior doctor at the military hospital of Aksha, a Russian post north of the border trade hub of Kyakhta. Examining a limited outbreak of bubonic plague in the autumn of 1894, Beliavsky came to the daring conclusion that tarbagans were carriers of plague and that the disease spread to humans whilst skinning or cutting the animal.4 His tarbagan hypothesis, articulated five years before Paul-Louis Simond’s celebrated paper on rats, was the first research-based theory to support the involvement of an animal vector in the spread of plague. As such it would exercise great influence on plague researchers and epidemiologists in the decades to come, with Wu’s verdict that marmots were the origin of the Manchurian plague outbreak of 1910-1911 (as expressed in the First International Plague Conference, April 1911, Mukden) being a definitive step towards its international endorsement.5

2 All in all, there is no doubt that the problem of the zoonotic origins of plague in the region is the most pertinent question when it comes to the historical analysis of plague related theories and policies in Northeast China and Inner Asia at large. However, this justified focus on the problem of zoonosis has left in the shadow of historical and anthropological analysis other contemporary trends in epidemiological thought regarding plague in the region. A major theme in this respect, which I wish to explore in this paper, was the problematisation of the locus and the trans-regional directionality of the disease, as developed in the period between Beliavsky’s founding plague research in the region, and Wu Liande’s world-renowned oeuvre following the Manchurian pneumonic plague of 1910-1911.

3 As Marta Hanson has demonstrated in her ground-breaking work, at the turn of the century the “geographic imagination” of disease played a crucial role in the constitution of both colonial and Imperial Chinese perceptions of what from a biomedical perspective we consider as epidemics.6 In the case of the Sino-Russian border area, prior to the 1910-1911 outbreak, the geographic problematisation of plague lay squarely in the hands of non-Chinese medical experts and explorers who contended for the explanation of three vital and interlinked (even overlapping) questions: a) where plague came from; b) in which areas was plague endemic; c) what was the direction of the spread of plague and why. It was evidently hoped that the elucidation of these questions could provide an understanding of plague in Northeast China and Inner Asia, compatible in its logic and language to the understanding of plague outbreaks in other places of the world at the time.7 This paper will examine attempts to generate such a geographic epidemio-logic, where by this term I mean a mode of reasoning about infectious disease outbreaks that takes geographic particularities and similarities, continuities and discontinuities, as key aspects of the epidemiology of a particular disease; a mode of investigating outbreaks by asking geographic questions about their origin, course and outcome. The paper will begin by examining the application of this particular epidemiological rationality as originating in the research of a prominent French medical doctor, Jean-Jacques Matignon. It will then move to consider how it was consequently developed by the leading Russian plague-expert, Danilo Kirilovich Zabolotny, and how it reached its paradoxical conclusion with the work of another Russian researcher of plague, Ivan Stepanovich Dudchenko-Kolbasenko. The paper will argue that the latter’s effort to bridge the

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geographic problematisation of plague with the tarbagan hypothesis was mediated by an epidemio-logical leap of faith: the acceptance on part of Dudchenko-Kolbasenko of the existence of man-eating marmots, and the constitution of this as an explanatory principle of plague outbreaks in the region.

Matignon’s expedition to Eastern Mongolia

4 Jean-Jacques Matignon was born in Eynesse of Gironde in 1866. He graduated with a medical degree from Bordeaux in 1892 and was stationed in Beijing as an army doctor attached to the French Foreign Legation in 1895. Matignon was a prolific author on a wide array of medical issues in China, dwelling principally on exotic and sensational topics: Forbidden City eunuchs, “acromegalo-gigantism,” foot-binding, Japanese mal- adaptability to Western boots, the Emperor Kangxi’s “neuropathy,” an alleged anti- leper pogrom in Nanjing, and a type of food poisoning, which he named atriplicism, inflicting North-Chinese beggars subsiding on an unwashed spinach-like herb.8 This medical-orientalist trajectory reached its apex in the publication of his magnum opus on Chinese “superstition, crime and poverty.”9 At the same time, however, Matignon was a practical man. He was active in the Peking Hospital as well as in medical expeditions to Manchuria, covering public health aspects of the Russian-Japanese War. 10 Yet what sealed Matignon’s international fame was his role as acting chief doctor of the Peking Foreign Legations during the Boxer siege of 1899-1900.11 All in all it may be said that by 1905 Matignon was the most recognised and admired French doctor operating in the Qing Empire.

5 It is not quite clear what first drew Matignon’s attention north of the Great Chinese Wall, a topic perhaps best left to his future biographers. What is certain is that as soon as he arrived in the Far East, he engaged in research in Urga, the capital of Mongolia (then part of the Qing Empire), as well as in what he called Eastern Mongolia, an area currently forming part of Inner Mongolia. In the case of Urga, Matignon investigated courtly Mongolian medicine, whereas in the case of Eastern Mongolia his interest lay with the study of bubonic plague. The results of his Eastern Mongolian plague expedition were first presented to the French Academy of Sciences in December 1897 and published in an extensive article in the Annales d’hygiène et de médecine légale in 1898, republished a year later in the Archives de médecine et de pharmacie Militaires.

6 Matignon began his paper La Peste bubonique en Mongolie Orientale, by giving a brief account of the displacement of Mongols by the Chinese and their confinement in “the great plateaux of Mongolia.”12 Describing the mountain ranges separating China from Mongolia, Matignon noted that the region, which was once covered in woods, now stood completely deforested as a result of the recent authorisation of Chinese migration by the Qing. Twelve days horse-ride away from Beijing to the northeast took Matignon to the valley of Sô-leu-kôn (Selenga) and the village of Toung-kia-Yng-tze, where “since nine years the bubonic reigns the plague.”13 Matignon wrote that the population of the valley was entirely Chinese: “the first colons consisted in Christians from the Manchurian border, who appealed to workers, mainly from the province of Shandon, to help them in their work of deforestation.”14 These Shandong migrants were looked down upon by the French doctor as paragons of hygienic backwardness: “The hygienic conditions in which this population lives are most faulty [défectueuse]. The houses are filthy slums, real huts of savages, made of mud walls and thatched

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roof.”15 Describing the structure of the huttes des sauvages in detail, Matignon stressed the role of the heated floor-bed commonly found in the region (kang, spelled by Matignon as kahn). “Come winter,” he wrote, “everything is carefully sealed and the air will not be renewed until the return of spring.”16 Crowdedness in the local houses, and the tendency to keep sick members of the family indoors, alongside healthy individuals was seen as generating a “revolting bodily filth” hence providing “an excellent terrain” for the development of typhus, smallpox and trachoma (ophtalmie granuleuse).17 Matignon decried that nowhere else in China or Korea had he seen such “sordid people”: “Most inhabitants wash their body but once a year. Soap is a thing absolutely unknown. The clothes are a block of dirt, worn for years, until they fall, somehow, in deliquescence.”18 Moreover, he noted that the garments of those who died of “contagious disease are not disinfected nor washed and are worn by some member of the family of the deceased.”19 As far as corpses were concerned, they were so carelessly buried that the first big rain brought them up to the surface. When it came to incidents of mass mortality, such as in the case of epidemics, Matignon claimed that corpses were simply thrown down a ravine nearby the village where they were devoured by wolves when the night fell.20

7 These conditions, Matignon argued, were ideal for the development of plague: “the habitats, houses, and soil are all receptacles in which Yersin’s bacillus can easily wait for an opportunity to manifest its virulence.”21 He further claimed that to these general factors contributing to the spread of plague one should add a more particular one: once the disease appeared in a household, it was not only the parents who stayed in the house in constant contact with the sick, but also neighbours who visited, “passing the hour, talking, smoking [and] drinking in the chamber of the pest-inflicted [pestiféré].”22 Only after the epidemic reached great proportions, like in 1896, did fear force people to avoid patients. “Plague-pneumonia,” as Matignon described the disease following medical conventions at the time, was seen as easily transported in the form of sputum sticking on clothes, shoes, and human hands: “I saw a man removing with his fingers from the mouth of his daughter sputum too sticky that it stuck to the teeth and lips. This accomplished, our man wiped his hands on his pants and after a while, without washing, began to eat.”23

8 Plague, according to Matignon, first appeared in the village of Yan-che-kou, at the northwest of Toung-kia-Yng-tze in September 1888, when a twenty-year-old girl, who had never left the small valley, became the first victim of the disease. The pestilence, Matignon, noted, “seems to me to have been imported by the workers, who, every year, arriving in spring from the southern provinces, mainly that of Shandong, to help the natives in their work.”24 Matignon noted that Shandong was not a foyer of plague, “yet the population of its coasts accounts for numerous sailors who work on cabotage in all the ports of the Chinese seas, going to Amoy and Canton, centres of plague, in transporting merchandise, clothes from all kinds of sources, where from many [people] may have fallen victim to plague. These clothes, purchased by workers, who go to Mongolia, have been used as a vehicle for germs of epidemic disease that seems now to have such strong roots in the valley of Sô-leu-kôn.”25 Hence he proposed that plague was not native to Eastern Mongolia, but was rather imported there from South China on the backs of pestilent coolies.26

9 Matignon was interested in the geography of epidemics, and engaged in what Marta Hanson has called “visualisation of the geography of diseases.”27 His work was

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accompanied by two maps. One map traced the progress of plague in Selenga valley, in 1896 and 1897.28 In a fashion similar to the one sported by Emile Rocher in mapping the spread of plague in Yunnan twenty years earlier, Matignon drew arrows showing the imagined spread of plague between Eastern Mongolian villages over time.29 The second map provided a larger view of China, clearly demarcating Yunnan and the area around Canton as “centres of plague,” with no equivalent “centre” in North China or beyond. Instead, the same map suggested that plague spread from Toung-kia-Yng-tze through Mongolia and Kyakhta (misspelled Kiarta) all the way to Irkutsk. This indicated that Matignon had probably come across literature on plague in Transbaikalia, although, in fact, no plague outbreak had been reported in the city of Irkutsk itself. Moreover it made clear that he considered Eastern Mongolia as a transit point, rather than as an endemic centre of the disease.30

10 Matignon was also interested in ethnography, and had already studied Mongolian courtly medicine, interviewing the Living Buddha’s chief physician in Urga.31 In his famous “superstition” monograph, Matignon claimed that in the course of his plague expedition to Eastern Mongolia “serious people recounted that [the 1896] plague was brought by a black bull, every night, some times before the appearance of the first cases, between 9 and 10 o’clock, bellowing in a terrible manner, pouring fire from his eyes and nose, having descended in gallop from the Mongolian plateau to the Selenga valley.”32 Matignon claimed that many natives said they had seen the animal with their own eyes, a belief shared by a Chinese priest “who despite practicing the Christian religion, was not totally stripped of Celestial superstition.”33 The withering of the epidemic was said to be indigenously attributed to the appearance of two red-tunic Lamas walking alongside the Selenga River radiating a resplendent flame from their headgear.34

11 In spite of his keen ethnographic interest, Matignon made no mention whatsoever of marmots, let alone of their relation to plague.35 He nonetheless noted that, unlike in South China, no rat epizootic accompanied the epidemics, although a great number of flies seemed to be lying dead in the chambers of plague-inflicted patients.36 He hence identified the disease as contagious: “A grave typhoid disease, almost always complicated by buboes, sometimes by expectorations similar to these of pneumonia, with very rapid development [and] fatal termination in 99 out of 100 cases: that is how Mongolian plague may be defined.”37 Matignon was confronted with the classic diagnostic problem regarding pneumonic plague in the absence of bacteriological testing: a pneumonic condition resembling many other infections, with an erratic appearance of buboes, which were usually symptomatic in the first victim of the disease (developing first lymph and then lung infection), or, in rare cases, in patients suffering from pneumonic plague relapsing into bubonic form. In a stroke of medical insight, Matignon readily acknowledged this problem, and went on to provide some detailed case studies of plague, which he observed in the field. An advocate of drastic measures, he proposed that the only way of eradicating plague in the region was burning the Chinese migrant houses with all their possessions inside, as “their value is anyway minimal,” warning, at the same time, that this being accomplished, graves would still pose a source of infection.38

12 Matignon reasoned that the limited needs of Selenga valley inhabitants “have so far been the best obstacle in the spread of plague. These Chinese seldom exit the valley, soil products being sufficient for their needs.”39 However, he feared that protracted

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contact with commercial centres could pose an international public health danger, with the disease spreading to Russia in the North through the large trading centre of Lama- miao, which was in direct communication with Kalgan, the main Chinese hub for tea and skin exports from China to Russia via Mongolia. “The day or the occasion when plague reaches Kalgan,” Matignon reasoned, “Russia will be seriously menaced.”40 Hence Matignon saw Eastern Mongolia as a potential transfer node of bubonic plague from South China to Mongolia and Transbaikalia. In this sense we can say that, focused on the role of trade in spreading plague, Matignon followed the orthodox epidemiological problematisation of the infection during the third plague pandemic: he added next to the great plague-spreading harbours of the South (Hong Kong and Bombay)41 a continental sibling, which by means of caravan-led trade could spread the disease along the ancient tea and fur trading routes of Tartary.

Matignon’s international reception

13 Matignon’s study of plague in Eastern Mongolia had a significant impact on international plague literature at the time, as already evident a year later in the Twenty-Eighth Annual Report of Bruce Low, a highly influential medical officer of the British Empire.42 Low put emphasis on trade and dirt as factors in the generation and spread of the disease. As Robert Peckham has demonstrated in his recent work on the third plague pandemic, the two categories were intricately linked in Victorian imagination of pestilence, with the “conflated idiom of trade and plague functioning at once as metaphor, even as it reflected the practical challenges posed by potentially- contaminated goods.”43 Drawing on Matignon’s report, Low stressed that these unhygienic subjects were not indigenous to the region but “a people who originally came from the province of Chang-Tong [Shandong], or the frontier of Manchuria”; roaming labourers who “occasionally go to So-len-ko Valley to assist in agricultural work.”44 A crucial event validating Matignon’s importation theory in the eyes of the British Colonial Office was the 1899 bubonic outbreak in the free harbour of Newchwang (Yingkou) in Southern Manchuria.45 The link was retrospective in so far as Matignon’s findings came before rather than after the manifestation of plague in the Manchurian port; still, it appeared both logically and geographically evident from the perspective of the imagined pathogeny of “imperial interconnectedness.”46

14 Medical journals were quick to report Matignon’s findings. In May 1898 The British Medical Journal made brief note of his expedition, whilst two years later (August 1900) it returned to the subject, putting emphasis on the cramped and dirty Chinese dwelling conditions. The journal repeated Matignon’s warning that “the new [plague] centre is a considerable menace to Russia, which has a large trade in tea and skins with Kalgan, which is quite near.”47 The same year Matignon’s findings were presented to the English-speaking medical public by a highly influential article to The Journal of Tropical Medicine authored by Franck G. Clemow. The paper was primarily a comprehensive review of Russian research on the tarbagan origins of plague in Transbaikalia, a hypothesis fully endorsed by Clemow, a very influential medical author for The British Medical Journal and The Lancet at the time. 48 Hence Clemow was the first English- language author to bring Matignon’s importation hypothesis face-to-face with the Russian tarbagan hypothesis. In an effort to balance the two theories and their mutually contradictory origin hypotheses, he argued for the existence of two

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epicentres of plague in what we now call Inner Asia. On the one hand, Transbaikalia, where the disease was carried by marmots. And, on the other hand, Eastern Mongolia where plague appeared to have no such zoonotic link, as “if these animals take any share at all in the spread of the disease, they do so to an incomparably less extent than in the case of the Siberian disease.”49 Clemow warned his readers that despite similarities, the two plague epicentres differed profoundly: The Siberian centre is, apparently, in a flat steppe country; the Mongolian in a valley amongst hills, and at a considerable height above sea-level. In the former the disease occurs only in certain years, in the autumn, and solely from contact with infected tarbagans. In the latter it breaks out every year, in the summer, and quite independently […] of disease in the lower animals. In the former it attacks only the members of the household of the first person affected, or others who have come into immediate contact with him or them, and each outbreak is thus limited to a clearly defined group of cases; in the latter it becomes epidemic over a considerable area, it is erratic in its course, it attacks a very large proportion of the entire community in a number of separate houses and separate villages, and there is no proof, apparently, that each fresh case is due to direct contact with a preceding case.50

15 The keen plague-watcher did not overlook the possibility of a connection between the two plague zones, although his support of this scenario was so haphazard as to attract the indignation of an anonymous author in The British Medical Journal at the time. 51 What is, however, truly perplexing is that although Matignon’s famous report never once mentioned marmots, many authors tended to fuse Matignon’s work with Beliavsky’s tarbagan hypothesis.

16 A prime example of this is Louis Boucher’s influential work on plague. In his 1901 address to the French Academy of Sciences at Rouen regarding a “permanent foyer” of plague, Boucher referred to the “so mysterious and so little explored” Central Asian plateau “among the populations of eastern Mongolia,” which he described as “perhaps the poorest on the plane,” where from “evil spreads to the north, in the region of lake Baikal, and to the south, in the mountain massif of Yunnam [sic] where it is definitively established.”52 This idea no doubt derived from a peculiar fusion of Matignon’s research with the endemic hypothesis of Zabolotny (see below). Yet Boucher’s major slight of hand was in claiming that Matignon’s findings related to zoonosis, and the tarbagan in particular: “In these regions where poverty and uncleanliness [la misère et la malpropreté ] are incredible, there exists a sort of rodent of the marmot family, the arctomys bobac or tarabagane [sic] whose role in the conservations and transmission of plague would be considerable.”53

17 We cannot be certain about the source of this error, but a couple of possibilities appear more likely from a bibliographical perspective. The first scenario is that the confusion stemmed from a short appraisal of Matignon and his plague expedition by the future Nobel laureate Alphonse Laveran to the French Academy in 1900.54 The illustrious Academician acknowledged Matignon’s contribution to the study of plague in Mongolia, whilst at the same time mentioning Russian studies on “tarabagan disease” in the area: “In 1897 Mr Matignon first noted the existence of foyers of plague in Mongolia, and his observations were confirmed by the Russian expedition for the study of plague.”55 Though a careful reading of his address makes evident that Laveran never actually claimed marmots to figure in Matignon’s work, the proximity of the two “outbreak narratives,” in Wald’s sense of the term, may have been the cause of the confusion at hand.56 This is for example evident in Low’s report on Laveran’s appraisal

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of Matignon’s work, where the British colonial medical officer clearly succumbs to this confusion of sources.57 An equally probable source is yet another short note, this time in the Dutch medical journal Janus, authored by Dr Stekoulis of Istanbul, another prolific but long-forgotten author on infectious diseases at the turn of the century. Stekoulis claimed that Matignon’s expedition to Eastern Mongolia took place in response to an urgent call by Belgian missionaries operating in the region.58 The said fathers were supposedly alarmed by news about the Indian plague epidemic, realising that a disease they described as “tarbagan pest” amongst their flock may be no other than bubonic plague.59 How the Istanbulite Greek came to this conclusion is not clear, for whereas Matignon does mention the fathers briefly, he never claims that they were the ones who alarmed him to the existence of plague in the region, nor does he ever mentions marmots. It is likely that this anecdotal information was the source of future portrayals of Matignon as supporting the tarbagan hypothesis. Interestingly, Clemow further contributed to the confusion by claiming that it was Matignon who wrote the November 1899 Janus article. Hence the words of Stekoulis regarding the Belgian fathers were put in the mouth of Matignon.60

18 Whatever the case may be, the ripple effect of Matignon’s research did not take long to reach St Petersburg, where in the spring of 1898 the newly founded Plague Commission decided to investigate matters further, by dispatching an expedition to Eastern Mongolia. Head of this fact-finding expedition on plague was one of the most prominent and charismatic epidemiologists in Russia at the turn of the century: Danilo Kirilovich Zabolotny.

Zabolotny’s expedition to Weichang

19 Zabolotny (1866-1929) was a well-educated and progressive medical scientist from the Ukraine, who was expelled from the University of Odessa for student activism in 1889. Between 1896 and 1897, his participation in clinical and experimental research on plague in India during the great epidemic won him international repute.61 Besides Zabolotny, the expedition party comprised of Radnazhap Budaevich Bimbaev, Vladimir Taranoukhine, and a Cossack guide named Schiline.62 The team boarded the Trans- Siberian railway on June 4 1898, and then crossed the Mongolian border into Qing territory via Kyakhta, reaching Beijing on horseback after having crossed the Mongolian plateau. Following further arrangements in the imperial capital, Zabolotny and his team crossed the imperial hunting grounds of Weichang and reached Toung- kia-yng-tze, lying at the outskirts of the great woodlands. A summary of the original findings of the expedition was first published in Russian in the September 1899 issue of the Russian Archive of Pathology, Clinical Medicine and Biology, and, subsequently, in the November 1899 issue of the Annales de l’Institut Pasteur.63

20 Zabolotny described the village previously studied by Matignon as “not too big, but very populous. The Chinese houses, called ‘phanses’, are covered in straw; they are small, being composed of two rooms and contain generally speaking a family of 10 to 20 persons.”64 The doctor characterized the local population as Chinese, with a few Mongols who “spoke Chinese and already had Chinese mores.”65 When it came to plague, Zabolotny alleged that “almost all the plague-inflicted were Catholics; hence, in frequenting each other, they have more chances of being contaminated than the pagans who avoid the sick.”66

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21 Zabolotny was met by a group of missionaries (Zabolotny seemed unsure if they were Belgian or Dutch) led by father Léon Desmet, who provided “valuable information on the cases prior to our arrival, and on the current illness.”67 According to the head of the mission, in the last dozen years the disease had been breaking out in the region annually in the summer months, having first made its appearance in Christian villages north of Selenga, not very far from Toung-kia-yng-tze.68 Father Léon claimed that in that year alone twenty-four people had been taken ill; all bore buboes or suffered from pneumonia, and all had succumbed to the scourge. Without delay Zabolotny set out to gather more information on the disease: This is what we have learned. The epidemic has been known here for ten years now under the name of ven-i, ven-tszay, khai-ven; this was imported from North-East Mongolia. The Chinese consider the illness as incurable. They distinguish between two forms: the pulmonary form, whose gravest symptom is hemoptysis, and the bubonic form, which is characterised by the appearance of gada —the buboes. Entire families perish [of it]. When the Chinese perceive a bubo on someone in their family, they pinch, in the form of a treatment, the skin around the bubo. This forms ecchymoses which confer an appearance of marble on the patient’s skin; some doctors have taken these spots for those of plague. In the pneumonic forms, they have the habit of covering with such form of artificial ecchymoses all the anterior part and the lateral parts of the thorax.69

22 Zabolotny explained that there was no health service to people infected by the disease in the area, adding in a tone reminiscent of Matignon’s treatises on superstition, as well as wider anti-Chinese prejudices in the West at the time: “The Chinese, fatalist by his nature, does not care about death. We may announce to him, without digression, that he will die tomorrow or even today, without these news having the power to impress him; he will merely thank you, meet his family so as to bid him farewell and share with them his last wishes.”70

23 Establishing an impromptu laboratory in the local church, Zabolotny was himself able to observe the disease in the case of a few individuals, starting with a thirty-year-old Chinese doctor who was taken ill on September 3 1898 at Maliento, a Chinese village near Toung-kia-yng-tze. Cultures developed from the ill man’s bloody sputum appeared to contain plague bacilli. The patient died before twenty-four hours had elapsed from the first signs of fever. As performing an autopsy was culturally unthinkable, Zabolotny opted to procure liquid from the man’s lungs, hence developing cultures that proved to contain plague bacilli, which once injected into animals (rats and mice) gave positive results. Zabolotny concluded his experiments by diagnosing “Pneumonia pestica.”71 He was also able to isolate plague bacilli from buboes of patients suffering from the bubonic form of the disease.72 Zabolonty’s conclusion was unambiguous: “It is certain that we are here, in Eastern Mongolia, in presence of an endemic foyer of bubonic plague which, according to testimonies by missionaries and by doctor Matignon, has existed already for more than ten years.”73

24 Hence, whilst acknowledging Matignon’s contribution in opening up the field of plague research in the region, Zabolotny was careful not to adopt his importation hypothesis. Claiming plague to be endemic, he sought to problematise the region as posing a threat to outlying territories: “the proximity of many great routes render this foyer excessively dangerous for China, as well as for Mongolia, Manchuria and, by consequence, Russia.”74 It was at this point that, wondering about the origins of the disease, Zabolotny alerted his readers’attention to the existence of so-called tarbagan plague in Mongolia proper: “This disease is very contagious. The Buryats who feed on the tarbagans,

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without cooking them properly, take a disease that, according to the descriptions of Russian doctors, presents septicaemic characteristics, with very violent fever, somnolence and tumefaction of the ganglions. This disease carries a very high mortality rate.”75

25 It is true that in the numerous articles deriving from the expedition, scarce mention is made of marmots or tarbagan plague, and yet Zabolotny did acknowledge the potentially important role of the particular rodents in transmitting plague amongst humans in the wider region. Two years later, in a longer article published in two installments in the Russian journal Archive of Biological Science, Zabolotny once again tacitly mentioned the tarbagan hypothesis, by reference to Beliavsky: “If we look at the presence of the endemic focus of plague in Mongolia, on the one hand, and on the other hand the cases of tarbagan plague previously described by Russian doctors and also observed in humans, we must conclude in favour of the identity of the tarbagan illness and true plague.”76

26 As Zabolotny is best known in medical history for his defense of the tarbagan origins of plague during the Manchurian epidemic of 1910-11, it is paramount to observe here his ambivalent position on this matter during the preceding decade. Although he clearly kept clear of Matignon’s importation theory, his mind lingered between two alternative possibilities: plague stemming from tarbagan in Mongolia proper, and plague being actually endemic around Weichang in Eastern Mongolia. A map taking the larger part of a page at the end of his 1899 French article and also featured in his second paper to the Russian Archive of Pathology, Clinical Medicine and Biology the same year, portrayed regions believed by Zabolotny to be “hearths” (ochagi) of plague.77 The map was titled “Map of Endemic Hearths of Plague” and bore a handwritten note: “Note! Designated hearths where plague is bacteriological ascertained.”78 These included Assyria, Mesopotamia (with a question mark), Kisiba (in Tanzania), , Garhwal, Kumaon (both British Indian districts at the time), Yunnan, Canton, as well as a region designated with capital letters as Eastern Mongolia comprising of three localities: Weichang, “Toun-tsta-tuzu” and Khingan. Mongolia proper and Transbaikalia are absent from these shaded territories, whilst Eastern Mongolia is independent of the Southwest Chinese endemic zone. A second hand-drawn map portrayed the “Position of endemic hearths in Eastern Mongolia (Weichang region).” It showed Weichang in shaded grey with broken lines connecting it with towns all the way to Beijing and Tianjin in the south. A second broken line connected Beijing with Kalgan and, ultimately, Urga.79 The “geographic imagination” of plague fostered by Zabolotny was, we can say, multi-focal, and in this scheme of things Eastern Mongolia possessed a place next to other alleged international endemic zones of the disease. As we have already seen, this endemic hypothesis was adopted by international medical figures like Boucher, creating a third pole in the imagination of plague in the region.

27 It is hence evident that, already by 1900, we have three distinct hypotheses regarding the origins of plague in Inner Asia: a) Beliavsky’s tarbagan hypothesis, which claimed that plague is harboured by Siberian marmots, spreading to humans in Mongolia and Transbaikalia via blood-to-blood contact of the animal whilst harvesting its fat, meat and fur; b) Matignon’s importation hypothesis, which claimed that plague is brought from South China to Eastern Mongolia by Shandong coolies employed in deforestation, and then, potentially spreading to Mongolia and Siberia via the tea and fur trade routes; c) Zabolotny’s endemic hypothesis, which claimed that plague is permanently

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present in Eastern Mongolia; this hinted at a possible involvement of marmots but did not commit itself to either a zoonotic nor a human contagion link, leaving the question of pathogenesis open. The co-existence of these three distinct and implicitly contradictory hypotheses posed a serious problem to Russian plague experts, who were engaged in the systematic study of plague in Mongolia and Transbaikalia.

28 In the ten years preceding the 1910-1911 devastating pneumonic plague outbreak in Manchuria, which would render the question of the origins of the disease in the region a topic of international interest, no less than twenty original research papers on plague in Transbaikalia and Mongolia were published in the Russian medical press. Although Russian researchers largely sided with Beliavsky’s tarbagan hypothesis, over the most part of the first decade of the twentieth century, the mystery of the role of the Eastern Mongolian foyer lingered as no Russian expedition was able to reach so far into Chinese territory after Zabolotny in order to re-examine the situation. The solution to this problem was to be given by the last major contributor to the study of plague in the region before the 1910-1911 Manchurian outbreak: Ivan Stepanovich Dudchenko, also known as Dudchenko-Kolbasenko.

Dudchenko’s hybrid hypothesis

29 Dudchenko was part of a Special Commission sent in 1908 to South Transbaikalia to investigate plague; he provided two major papers deriving from the expedition, which were to have a significant impact on medical perceptions of plague in the region.

30 Dudchenko was interested in examining the extent to which Zabolotny’s theory on the Weichang origins of plague was contradicted by plague cases found in Mongolia and Transbaikalia. Key to his argument was the observation that the actual place where one finds plague-infected individuals should not be mistaken for the place where the disease originates. Dudchenko noted that the entire region under question was thick with major human traffic networks. From Buddhist pilgrims and tea-block traders, to Imperial envoys and Bannermen, anyone who wanted to reach Urga from Beijing and further afar had to pass via Zabolotny’s plague zone: “It seems obvious that travelers from distant places, people weakened by road deprivation, with low natural resistance, can easily be infected with plague, driving slowly on camels across the plague focus, staying there for the night.”80 Thus, a road-weary pilgrim or trader would stop at one of the villages near Weichang, contract the disease and thence travel into Mongolia carrying plague. So far, this hypothesis did not differ greatly from Zabolotny’s speculations, or Matignon’s fears. Yet at this point Dudchenko introduced a crucial link that would bridge it with the tarbagan hypothesis. Dudchenko argued that as the infected pilgrim or trader reached Mongolia, he or she would soon succumb to the disease and would be subjected, according to the Lamaist custom, to a sky burial. In other words, the plague-infected corpse would be exposed to the elements and any carrion caring to eat its flesh. What rendered this ethnographic speculation an exegetical tool in defining the trans-regional dynamics of plague was Dudchenko’s claim that the sky burial of plague victims offered the opportunity to marmots to eat the infected corpses of unfortunate travelers and hence infect native hunters in turn.81

31 In support of this hybrid hypothesis, which was to fascinate epidemiologists for decades, Dudchenko offered further evidence in a short entry to the Russian Archive of Pathology, Clinical Medicine and Biology (November 1909). There he revealed information

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secured by a local vet, according to whom although plague afflicted humans in the region, marmots did not suffer from the disease, hence supposedly proving that rather than being the original hosts of plague, they were in fact but secondary victims of this human-derived disease. Dudchenko attributed the lack of marmot infection in the particular region to the fact that, as Muslims, the Kirgiz of the region in question buried corpses of plague victims rather than exposing them to sky burials like the Mongols: The plague has not been apparently brought to the Akmolinsk , but even if it was, it did not spread among marmot-tarbagan due to the burial customs of the Mohamedan Kirgiz who bury their dead underground and who therefore did not hitherto encounter this illness. It is known that dead bodies of the Mongols are left on the surface instead of burial, and that from plague-ridden corpses the plague is passed to the marmot-tarbagan as the latter devour dead bodies.82

32 This circular explanation of plague was crucial for Dudchenko as it elucidated why humans were infected by plague only in the late summer or early autumn. According to his calculations, this was the season when pilgrims and traders returned from their travels south by way of Weichang, thus first infecting marmots, which then infected humans in turn.83 Hence Dudchenko claimed that the reason why there were more frequent outbreaks in Mongolia than in Transbaikalia was not only because the former’s proximity to Weichang but also because therein sky burial was religiously observed. By contrast, Transbaikalia was more distanced from the endemic focus of plague, and its population was also supposedly less observant of Tibetan Buddhist death rites.84

33 In order to illuminate this connection, Dudchenko published a map of this trans- regional infection route that warrants close examination.85 The map, titled “Schematic Map: еndemic hearths of plague in northern China and adjacent parts of southern Transbaikalia and northern Mongolia,” featured two encircled regions: Weichang and the Mongol-Chinese border. The former bore in brackets the note “hearth [ochag] of endemic plague in North China,” whilst the latter the note “hearth of endemic plague in south Transbaikalia and north Mongolia (tarbagan region).” Dudchenko drew two routes, both ending in Wutai, southwest of Beijing. The first crossed the western reaches of Weichang and ended up in Kubukhaevskay village, a few miles southeast of Aksha. The second crossed the eastern reaches of Weichang and ended up in Borzia, the major railway station before the Chinese border on the Chinese Eastern Railway line. Both trajectories were marked as “caravan routes,” with arrows on the sides of the routes noting that the traffic (and perhaps the direction of infection) was bilateral. It is not clear whether Wutai referred to the city or to the region of Wutaishan, but given that the latter was at the time a major Tibetan-Mongol Buddhist hub, it is likely that Dudchenko took the monastic complex for his reference. Wutaishan’s significance as a pilgrimage destination for Mongols at the turn of the century has been recently studied by Isabelle Charleux, who has demonstrated that the particular religious practice was a process involving elites as well as ordinary Mongols. The pilgrims’motivation was karmic, therapeutic, and related to burying the bones of their parents in the holy land. Such goals did not exclude trade, which flourished in the monastic complex especially during the celebrated horse and mule fair on the sixth month of the Lunar year, coinciding with what Dudchenko considered as the peak of plague-spreading patterns in the region.86

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34 We need to pay close attention to the importance placed on this Buddhist link for two reasons. First, because it reproduced the then dominant “outbreak narrative” connecting epidemics to pilgrimages in different parts of the globe. Second, because it contradicted the dominant Russian narrative regarding the relation between Tibetan- Mongolian Buddhism, known at the time as Lamaism, and plague, which contended that the particular form of Buddhism functioned as an inhibitor rather than as an amplifier of the disease in the region.

35 The Victorian imagination of pilgrimages as modes of transportation and sustenance of a wide array of infectious diseases is a topic that warrants sustained examination, which cannot be performed here. This attribution of pestilence was primarily connected with problematisations of the haj to Mecca as a conduit of infectious diseases.87 In this wider context of epidemiological rationality, the problematisation of other pilgrimages operated within the boundaries of a global “geographic imagination” whose role was to connect different regions of the world nosologically.88 Pilgrimage thus functioned as gravitational point of Victorian epidemiological rationality, in other words, as an epidemio-logical operator that allowed for the pathologisation of colonised (or semi-colonised) subjects’religious activities.89 In this respect, it is interesting to note that the Mongolian pilgrimage to Wutaishan was not the sole object of epidemiological problematisation in the region. Dr Levin, empowered by the Tsar to investigate the 1898 plague outbreak in Anzov claimed “that this disease and the outbreaks of plague on the lower Volga and on the Caspian […] might be due to carriage of infection from Mongolia by means of Kalmuck and Kirghiz pilgrims who might have visited certain sacred Moslem shrines in Mongolia, and brought the disease back with them.”90 In his influential book Geography of Epidemics, Clemow protested that distances between the two regions were impossibly vast, and that the Muslims “of the Kirghiz steppes east of the Volga are said to have no holy places of any kind in Mongolia, while the Kalmucks, who live to the west of the Volga, are despised and looked upon as heathens by both Mongols and Kirghiz and are not allowed to pass the Kirghiz steppes.”91

36 What differentiated the epidemiological problematisation of the Wutai pilgrimage was its place within the wider Russian medical literature on plague at the time, which proclaimed that Lamaism acted as an inhibitor to the spread of bubonic plague. This idea was first proposed by the eminent Polish physician, anthropologist and archaeologist Julian Talko-Hryntsewich who undertook a plague-related expedition to Mongolia in the autumn of 1899. In his much-quoted report to the bulletin of the Imperial Geographical Society’s Kyakhta branch, he provided a rather confused narrative on native understandings of outbreaks in the region, which nonetheless hinted for the first time at a connection between the alleged native knowledge of plague (a constituent part of Beliavsky’s tarbagan hypothesis) and the teachings of Lamaism.92 In particular, Talko-Hryntsewich claimed that the true source of plague was known to Mongols, as “it is said that ancient Buddhist religious laws forbid the consumption of the tarbagan and entering a temple wearing a fur coat [made from] that animal.”93 This information was, however, contradicted a few pages later when the anthropologist expressed serious reservations about Lamaist knowledge of plague in Mongolia. Interviewing a Lama on the disease, he admitted that the monk replied that it was a punishment sent by Burkhan (the Buddha) to sinners. Talko-Hryntsewich noted that the monk did not seem to understand the symptoms of the disease. This conclusion was seconded by a High-Lama, who claimed that the monks were so terrified

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of any disease that they would immediately flee from patients and refuse to treat them. Talko-Hryntsewich went on to claim that, in Urga, Lamas preached to Mongols that plague was the result of the spring lunar eclipse, and that the disease would be particularly severe were the eclipse total.94 Overlooking the inherent contradiction in Talko-Hryntsewich’s report, Russian plague experts sought to adopt the idea that Tibetan Buddhism endowed Mongols with a knowledge of plague. Hence in 1905, Dr Skrzhivan would write in the Russian Archive of Pathology, Clinical Medicine and Biology that knowledge of plague is evident in the writings of a certain Badmasambaboĭ (evidently the lotus-born Padmasambhava), “who has foreseen the disease to come from soil to plants, from them to animals and then to people.”95 Skrzhivan’s long and muddled portrayal of Tibetan theories of disease was sprinkled with quasi- ethnographic elements and inspired fascination amongst international epidemiological circles for the next three decades.96

37 Dudchenko did not ignore nor repudiate this Buddhist connection. Instead, he engaged in further speculation about the alleged Lamaist knowledge of plague. What is rather striking is Dudchenko’s apparent confusion on the matter. On the one hand, he noted that Buddhist monks who functioned as doctors in the region had no idea of contagion and thus spent entire days in the same yurt with patients—a fatal attitude in case of pneumonic plague, the most common clinical form of the disease in the region.97 And yet, at the same time, he seemed ready to forsake his skepticism and indulge in furthering the Lamaist connection as regards the native knowledge hypothesis, providing a story which would resonate in epidemiological writings for the years to come. He thus recounted that in October 1908 a Lama arrived at the monastery of Tosakh bringing news of a great epidemic that had devastated the encampment of Tsanid-Gegen in Ulyast, himself being the sole survivor. Following Dudchenko’s narrative, “the Tosakh Lamas decided that the Tsanid-Gegen and his men had died of plague,” and decided to lock-up the monastery, letting no one in or out for thirty days: “Every day at a certain hour of the day all the inhabitants of the monastery came out into the open courtyard of the monastery and formed a line. Lamas of neighbouring datsans appeared at the same time on a nearby hill, and through binoculars accounted for all the people under quarantine, according to prearranged signals.”98 So successful was the “quarantine,” that, in the words of Dudchenko, no one died in the “Tosakh joss- house.”

38 What begs explanation at this point is how Dudchenko’s appraisal of Lamaism as plague-preventative relates to his simultaneous condemnation of it as the very means through which the disease spread across Inner Asia. Clearly the crucial link here, the key to this epidemio-logical incoherence, is the mytheme of the man-eating Siberian marmots, in Lévi-Strauss’s sense of the term, as the latent operator or constitutive element of Dudchenko’s epidemiological rationality.99

39 The outlandish idea that marmots eat human corpses should be sought in a chance encounter between a Russian epidemiologist, a human bone and a marmot hole. In 1900, Anatoly Podbel’sky organised a plague-finding expedition to Mongolia. There is no space here to do justice to the extensive and elaborate report of the doctor, published on December 30 1901 in the Russian Archive of Pathology, Clinical Medicine and Biology. What is crucial to our story is that, at the same time as conducting field observations on the tarbagan, Podbel’sky made another, rather accidental, discovery, which would assume its own life in epidemiological literature in the years to come:

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Three yards from the exit hole was found a yellowed human tibial bone. Its epiphysis seemed to be broken off. Seven yards from the entrance of the burrow the ground was littered with the frontal and occipital bones of a human skull. The rest of the skeleton bones were not found.100

40 Podbel’sky risked no explanation of this discovery; he merely mentioned, half jokingly, that marmots are playful animals and may have used the bones for sharpening their mighty incisors. On a more sombre note, he also noted that one should not rule out the possibility of an infection from human corpses to Siberian marmots, in case the former had died of a “contagious disease, for example plague.”101

41 This short passage would have been no more than a typical anecdotal entry in the chronicles of an expedition, and would have indeed remained a quaint footnote in the growing tarbagan literature if it was not for Georg Sticker who gave the story a whole new dimension. For in his Die Pest the influential German author re-invented the story, enriching it in a determining way. According to Sticker, the corpse was a plague victim, something Podbel’sky never asserted.102 Hence, readers of Die Pest were informed that, during sky burials, Mongols laid the bodies of the plague victims on the steppe where they were torn apart by carrion. As a result, their blood was said to soil the steppe grass so that marmots, which habitually fed on it, were infected. Adding more spice to his distorted and imaginative version of the original Russian paper, Sticker also added that tarbagan have the habit of dragging the bones of human plague victims into their nest, thus increasing the risk of infection.103

42 Seen from a critical anthropological perspective, we can say that the human tibial bone found by Podbel’sky near the marmot hole functioned as an epidemio-logical objet trouvé (found-object), in the surrealist tradition of the term. Or, if I may venture a bit further, as what the Rumanian surrealist poet and essayist Gherasim Luca called an “objectively offered object.” An object that exercises a force of catalytic encounter upon the subject that comes across it, radically transforming his or her perception of the ordinary into an extraordinary perception.104 In the surrealist tradition, the objectively offered object allows different narratives and imaginaries to come together in a plane of consistency that does not represent either a synthesis of their theses or an overcoming of their antitheses. On the contrary the objectively offered object forces an anti-dialectical leap of faith: in our case, the belief in human-eating marmots, which, in the hands of Dudchenko, became the logical key to a new epidemiological discourse about the trans-regionality of plague.

43 Hence Dudchenko instituted a transformed “geographic imagination” of plague. This rejected both Matignon’s hypothesis that the disease was imported from South China, and the original Russian tarbagan hypothesis, which argued that marmots were the original source of the disease. Accepting Zabolotny’s thesis that Eastern Mongolia was an endemic focus of plague (but also adding Transbaikalia as a second endemic “hearth”), this geographic epidemiological model envisioned the crucial route of plague-importation to run not from South China to Weichang, but in a circuit between Wutai, Weichang, Mongolia and Transbaikalia. And, at the same time, it inverted the zoonotic link established by previous research, by claiming that it was humans who infected marmots rather than the other way around. Through an epidemio-logical leap of faith, a stratagem in epidemiological rationality—the endorsement of the mytheme of man-eating marmots—Dudchenko turned Beliavsky’s tarbagan hypothesis on its head. The result was an apparently plausible if in fact surreal compromise between it, the

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endemic hypothesis of Zabolotny, and the trans-regional problematisation of plague transmission originally introduced by Matignon.

Conclusion

44 What had started in 1898, in the hands of Jean-Jacques Matignon, as a standard exercise in explaining plague outbreaks in a backwater area of North-East China in terms of a trans-regional importation theory that pointed the finger at the alleged geographic source of the third plague pandemic (South China) and the usual suspects (Chinese coolies) was within little more than a decade transformed by Dudchenko into a complex “outbreak narrative” that bridged colonial-medical problematisations of pilgrimage, Russian Orientalist fascination with Tibetan-Mongolian Buddhism and research pointing at Siberian marmots as the zoonotic source of plague in Inner Asia.

45 The three geographic epidemiological assemblages described above would prove a vital index of concepts come the Manchurian pneumonic plague outbreak of 1910-1911. The Matignon-Zabolotny-Dudchenko trajectory would equip the “geographic imagination” of epidemics with a platform for negotiating the relation between zoonotic infection and human contagion, leading by April 1911 to another major reconfiguration of its three sites of problematisation: population movement, human-animal interaction, and endemicity. In a stroke of epidemio-logical genius, Wu Liande, the leader of Chinese anti- plague efforts in Manchuria, would recombine these elements in a plausible form, convincing the international medical community that plague was endemic in Transbaikalia, that it was a disease of the tarbagan transmitted to humans whilst hunting the animal, which, turning pneumonic and airborne, was thence carried south by Chinese coolies.105

46 Rather than signaling the demise of more adventurous explanations (including man- eating marmots) in epidemiological literature, Wu’s model would become a canonical exegesis against which such elements, as well as new problematisations of the geographic and zoonotic aspects of plague in the region, would be evaluated. The controversial role of Wu as an epistemological referee in this process is beyond the scope of this paper, yet it is important to keep in mind, in terms of a concluding methodological precaution, that medical historians as well as epidemiologists should be particularly weary of relying on Wu’s synthesis of previous plague research in the region. As shown in this paper, the history of plague research and theory in Manchuria and Inner Asia was a far more multivocal, innovative and contradictory process than the linear narrative of scientific discovery retrospectively procured in the writings of the self-styled “plague fighter.”106

Theories of Plague Transmission in North-East China and Inner Asia

Mode of Endemic Geographic Route of Infection Route Infection/ Hearth Contagion Contagion

tarbagan to Beliavsky humans to ? ? hunting (I) 1894 humans

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South China to Eastern Matignon humans to South China Mongolia (to Mongolia/ trade & dirt (C) 1898 humans Transbaikalia?)

tarbagan to Zabolotny humans/ Weichang to Beijing (to hunting (I) & Weichang 1899 humans to Mongolia?) human contact (C) humans

humans to Weichang Circuit between Wutai, pilgrimage (C) Dudchenko tarbagan to &Transbaikalia/ Weichang, Mongolia and &sky burial (I) 1909 humans Mongolia Transbaikalia &hunting (I)

tarbagan to hunting (I) & Wu Liande Transbaikalia/ humans to Transbaikalia to China “floating 1911 Mongolia humans population” (C)

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LUCA Gherasim (2009). The Passive Vampire. Prague: Twisted Spoon.

LYNTERIS Christos (2013). “Skilled Natives, Inept Coolies: Marmot Hunting and the Great Manchurian Pneumonic Plague (1910-1911).” History and Anthropology, vol. 24, no. 3 (August 2012) : 303-321.

MATIGNON Jean-Jacques (1895). “La Médecine des Mongols.” Archives cliniques de Bordeaux, vol. 4, no. 11 : 515-523.

MATIGNON Jean-Jacques (1898a). “De l’atriplicisme (intoxication par l’Arroche).” China Imperial Maritime Customs Medical Reports, 54th issue, Shanghai.

MATIGNON Jean-Jacques (1898b). “La peste bubonique en Mongolie.” Annales d’hygiène publique et de médecine légale, Serie 3d, 39 : 227-256.

MATIGNON Jean-Jacques (1899a). “La peste bubonique en Mongolie.” Archives deMédecine et de Pharmacie Militaires, vol. 33 : 463-486.

MATIGNON Jean-Jacques (1899b). Superstition, crime et misère en Chine (souvenirs de biologie sociale). Paris, Masson et cie.

MATIGNON Jean-Jacques (1913). “La Destruction des Centres Lépreux en Chine.” La Chronique Medicale, vol. 20, no. 10: 289-291.

MEADE Melinda S., EMCH Michael (2010). Medical Geography. New York, The Guilford Press.

PECKHAM Robert (2013). “Infective Economies: Empire, Panic and the Business of Disease.” The Journal of Imperial and Commonwealth History, vol. 41, no. 2: 213-237.

PAVLOVSKY Eugene. N (1966). Natural Nidality of Transmissible Diseases. Chicago, University of Illinois Press.

PODBEL’SKY Anatoly I. (1901). “Nablyudenïi nad Tarbaganami v Mongolïi (Observations on the Tarbagan in Mongolia).” Russïĭ Arkhiv Patalogïi, Klinicheskoĭ Meditsinui i Baketeriologïi : 249-265.

ROCHER Émile (1879). La Province Chinoise du Yunnan. Paris, Lerous, 1879.

SKRZHIVAN F. (1900). “Nashi Svêdênïya o Tarabagan’eï Chumê (Our Data on Tarbagan Plague).” Russïĭ Arkhiv Patalogïi, Klinicheskoĭ Meditsinui i Baketeriologii : 603-612.

STEKOULIS (1899). “Contribution à l’étude de la peste de Mongolie.” Janus. Archives internationales de l’histoire de la médecine et la géographie médicale, vol. 4 : 617-618.

SIMPSON William. J. (1905). Treatise on Plague: Dealing with the Historical, Epidemiological, Clinical, Therapeutic and Preventive Aspects of the Disease. Cambridge, Cambridge University Press.

STICKER Georg (1908). Abhandlungen aus der Seuchengeschichte und Seuchenlehre, 2 vols. (Gießen : Töpelmann, 1908), vol. 1 (“Die Pest als Seuche und als Plage”).

STRONG Richard. P. (ed.) (1912) Report of the International Plague Conference (held at Mukden in April 1911). Manila, Bureau of Printing.

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SUMMERS William C. (2012). The Great Manchurian Plague of 1910-1911: The Geopolitics of an Epidemic Disease. New Haven, Yale University Press.

TALKO-HRYNCEWICZ Julian. D. (1899). “O Chumnuikh Zabolêvanïyakh v Mongolïi (On Pestilential Diseases in Mongolia).” Trudui Troichkoskago-Kyakhtinskago Otdeleniya Priamurskago Otdela Imperatorskago Russkago Geograficheskago Obshchestva, vol. 1, no. 1–2: 96-110.

TAGLIACOZZO Eric (2013). The Longest Journey: Southeast Asians and the Pilgrimage to Mecca. Oxford, Oxford University Press.

WALD Priscilla (2008). Contagious: Cultures, Carriers, and the Outbreak Narrative. Durham, Duke University Press.

WU Liande (1926). Treatise on Pneumonic Plague. Geneva, League of Nations.

WU Liande (1956) Plague Fighter: The Autobiography of a Modern Chinese Physician. Cambridge, Heffers.

ZABOLOTNY Danilo K. (1899a). “Pustulezna Forma Chumui (Pustular Form of Plague).” Russïĭ Arkhiv Patalogïi, Klinicheskoĭ Meditsinui i Baketeriologïi: 239-241.

ZABOLOTNY Danilo K. (1899b). “Epidemicheskïe Ochagi Chumnui na Zemnom Share i Prichinui eya Rasprostranenïya (Epidemic Foci of Plague on the Globe and the Reason for its Spread).” Russïĭ Arkhiv Patalogïi, Klinicheskoĭ Meditsinui i Baketeriologïi: 242-250.

ZABOLOTNY Danilo K. (1899c). “La Peste en Mongolie Orientale.” Annales de l’Institut Pasteur, vol. 13, no. 11 : 833-840.

ZABOLOTNY Danilo K. (1899d). Epidemicheskïe Ochagi Chumnui na Zemnom Share i Prichinui eya Rasprostranenïya. St Petersburg, K. L. Rikker.

ZABOLOTNY Danilo K. (1901). “Izcledovanïya po Chumê; Stat’ya Pervaya (Research on Plague; first article).” Arkhiv Biologicheskikh Nauk, vol. 8, no. 1: 59-77.

ZABOLOTNY Danilo K. (1907). Chuma (Pestis bubonica) Epidemiologia, Patogenez i Profilaktika (Plague Epidemiology, Pathogenesis and Prevention). St Petersburg, Interior Ministry Press.

NOTES

1. Gamsa 2006; Sean 2011; Knab 2011; Summers 2012; Lynteris 2013. 2. See the transcripts of the First International Plague Conference: Strong 1912. 3. Transbaikalia refers to the Russian territories east and south of Lake Baikal, currently divided into the Republic of Buryatia and Zabaykalsky Krai. 4. Beliavsky 1895. 5. It should, however, be noted that after Wu’s “reversal of verdicts” on the tarbagan hypothesis in his May 1913 Journal of Hygiene article, it would take another eight years until the full canonisation of the hypothesis, following Wu’s embarrassing re-endorsement in the aftermath of the second Manchurian plague outbreak (1920-1921). 6. Hanson 2011. 7. Before 1910 with exception of San Francisco, no major outbreak of plague had occurred north of the 40th parallel, whereas in the South the disease had ravaged Yunnan, Hong Kong, India, Australia, South and , parts of Latin America as well as Hawaii. It must be kept in mind that none of the two major plague epidemics in Manchuria (1910-1911; 1920-1921) formed part of the third plague pandemic.

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8. Anon. 1904; Anon. 1906; Anon. 1913; Matignon 1898a; Matignon 1913. 9. Matignon 1899a. 10. Anon. 1906. 11. Matignon was in fact for a time believed to have perished during the siege (Anon. 1900b: 268). 12. Matignon 1899a: 463. 13. Matignon 1898: 228. 14. Matignon 1899a: 464. 15. Matignon 1898: 229. 16. Matignon 1899a: 465. 17. Matignon 1899a: 465. 18. Matignon 1899a: 465. 19. Matignon 1899a: 465-466. 20. Matignon 1899a: 466. 21. Matignon 1898: 231. 22. Matignon 1899a: 466. 23. Matignon 1899a: 466. 24. Matignon 1898: 232. 25. Matignon 1898: 232. Shandong was spelled “Chan-toung” by Matignon, following the convention in both French and English at the time. 26. For a broader discussion on relating plague to coolies in China see Lynteris 2012. 27. Hanson 2011. 28. Matignon 1899a: 470. 29. Rocher 1879. Hanson (2012) has recently demonstrated that a year earlier Manson published the first map of the progress of plague in Yunnan. 30. For further discussion of Matignon’s maps and mapping disease in China in general see Hanson (2012). 31. Matignon 1895. 32. Matignon 1899b: 29. 33. Ibid.: 29 34. Ibid.: 30. 35. In his earlier article on Mongolian medicine he only mentions marmots as a source of anti- dysmenorrhea medications amongst Mongols (Matignon 1895: 522). 36. Matignon 1899: 472. 37. Matignon 1899: 473. 38. Matignon 1898: 250. 39. Matignon 1898: 481. 40. Matignon 1898: 481. 41. Echenberg 2007. 42. Low 1899. 43. Peckham 2013: 4. Peckham notes Simpson’s claim that the pathogen spread along the “most frequented trade routes” (Simpson 1902: 195; Peckham 2013: 11). Hence, he argues, Hong Kong was seen as a “disease hub” and plague as a “pseudo-commodity” (ibid: 13). 44. Low 1899: 124. 45. In this case too the openness of the harbour was seen as both source of wealth and death, with a special focus on the coolie labour force (cf. Peckham 2013: 15). However, in the case of Newchwang, the connection between Shandong coolies and the Boxers complicated matters further, making this a political as well as economic threat. 46. On the notion of imperial interconnectedness, see Peckham 2013: 7. 47. Anon. 1898: 1286; Anon. 1900c: 454. 48. Clemow 1900.

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49. Clemow 1900: 173. 50. Clemow 1900: 173-4. 51. Anon. 1900a: 540. 52. Boucher 1902: 136. 53. Boucher 1902: 152. 54. Laveran 1900: 155. 55. Laveran 1900: 155 56. Wald 2008. 57. Low 1901: 363; Low refers to Laveran’s report as made by Matignon, adding to the confusion. 58. Stekoulis 1899: 617-618. 59. Stekoulis 1899: 617. 60. Clemow 1900: 173. 61. Bilay 1966. 62. Bimbaev also provided his own account of the expedition (Bimbaev, 1899). 63. Zabolotny 1899a; Zabolotny 1899b; Zabolotny 1899c. 64. Zabolotny 1899c: 833. 65. Zabolotny 1899c: 833. 66. Zabolotny 1899c: 833. 67. Zabolotny 1901: 65. 68. Zabolotny 1899c: 834. 69. Zabolotny 1901: 66. For a discussion of term wenyi as a generic term on epidemics, and notions of contagion in Imperial China see Hanson 2011; Leung 2011. 70. Zabolotny 1899b: 835. From a total of sixteen cases observed, six were pneumonic, eight bubonic and one septicaemic. 71. Zabolotny 1901: 68. Two more patients were similarly diagnosed whilst three were found to suffer from bubonic plague. It must be noted here that Zabolotny claimed it was easy to procure samples through injection of buboes due to the above-mentioned pinching custom. For a very different discussion of popular perceptions of injection in the region see Rogaski 2011. 72. Zabolotny 1899c: 836. 73. Zabolotny 1899c: 837. 74. Zabolotny 1899c: 837, emphasis in the original. 75. Zabolotny 1899c: 837. 76. Zabolotny 1901: 74. 77. Zabolotny 1899b: 243. The same map is reproduced identically in Zabolotny’s 1899 pamphlet- size reprint of the second 1899 article (Zaboltny 1899d: 2), as well as in his 1907 monograph on plague (Zabolotny 1907: 6). 78. I would like to thank Susan D. Jones for bringing to my attention that ochag was rendered as “nidus” in the context of Eugene N. Pavlovsky’s work on plague (1966). For a discussion of Pavlovsky’s “landscape epidemiology,” see Meade and Emch (2010). 79. Zabolotny 1907: 7. 80. Dudchenko-Kolbasenko, 1909b: 1048-1049. 81. Dudchenko-Kolbasenko 1909a: 1698. 82. Dudchenko-Kolbasenko 1909a: 1699. 83. Dudchenko-Kolbasenko, 1909b: 1051. 84. Dudchenko-Kolbasenko, 1909b: 1078. 85. Dudchenko-Kolbasenko, 1909b: 1077. 86. Charleux 2011. It is interesting to note here that there is no medical record of plague outbreaks in the monastic complex. Whether there are records of epidemics in the monastic archives themselves lies beyond the expertise of the author. 87. Bulmus 2012; Tagliacozzo 2013.

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88. On the notion of nosology in the case of China, see Hanson 2012. 89. Arnold 1986. 90. Clemow 1903: 326. 91. Clemow 1903: 326. 92. On the ‘native knowledge hypothesis’see Lynteris 2013. 93. Talko-Hryntsewich 1900: 100. 94. Talko-Hryntsewich 1900: 101. 95. Skrzhivan 1905: 609. 96. Wu 1926. 97. Dudchenko-Kolbasenko 1909a: 1072. 98. Ibid.: 1076. 99. Lévi-Strauss 1955. 100. Podbel’sky 1901: 261 101. Podbel’sky 1901: 261 102. Sticker 1908: 123. 103. Sticker 1908: 123. 104. Luca 2009. 105. Strong 1912; Wu 1926. 106. Wu 1956.

ABSTRACTS

This paper examines the legacy of the 1896 Selenga Valley Expedition led by the French doctor Jean-Jacques Matignon on Russian research on bubonic plague in the decade preceding the great Manchurian plague epidemic of 1910-1911. With particular focus on Danilo Kirilovich Zabolotny’s expedition to Weichang (1898) and Ivan Stepanovich Dudchenko-Kolbashenko’s expedition to Mongolia and Transbaikalia (1907-1908), the paper will examine how Matignon’s hypothesis that plague was not endemic in the region but rather imported from South China on the back of so- called ‘coolies’was subsequently entwined with the Russian hypothesis of a zoonotic origin of plague, focused on Siberian marmots (tarbagan) as the endemic vector of the disease in Inner Asia. The paper will explore the role of Russian medical ethnography in forging a paradoxical hybrid between the two hypotheses, with Lamaism assuming a prominent role in forging a transregional model of bubonic plague. This was based on the mistaken assumption that marmots feed on sky-burial corpses of infected pilgrims and traders, hence proposing that it was humans who infected marmots with the disease, rather than the other way around.

Cet article analyse les retombées de l’Expédition de la Vallée de Selenga menée par le médecin français Jean-Jacques Matignon en 1896 sur les recherches russes autour de la peste bubonique dans la décennie précédant la grande peste de Mandchourie de 1910-1911. En s’attachant tout particulièrement à l’expédition de Danilo Kirilovich Zabolotny à Weichang (1898) et à celle d’Ivan Stepanovich Dudchenko-Kolbashenko en Mongolie et en Transbaikalia (1907-1908), il examine comment l’hypothèse exposée par Matignon, selon laquelle la peste n’est pas endémique dans la région mais importée depuis le Sud de la Chine par des « coolies », s’est trouvée imbriquée dans l’hypothèse russe d’une origine zoonotique de la peste, centrée sur les marmottes sibériennes (tarbagan), vectrices endémique de la maladie dans l’Asie centrale. Cet article étudie comment

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l’ethnographie médicale russe réussit à forger une hybridation entre ces deux hypothèses, mettant le Lamaïsme au cœur du modèle transrégional de la peste bubonique. Hybridation basée sur l’hypothèse erronée que les marmottes se nourrissent des cadavres des pèlerins et des commerçants, exposés à l’air libre, et que ce sont ainsi les humains qui infectent les marmottes et non l’inverse.

本文討論1896年(滿洲鼠疫(1910-1911)爆發前十年)由法國醫生馬丁榮(Jean-Jacques Matignon) 所 帶領的“色楞格流域考察”（Selenga Valley Expedition) 的成果及其對俄國在中國東北和內亞鼠 疫研究的影響。本文通過分析丹尼洛˙基裡洛維奇˙紮博洛特內（Danilo Kirilovich Zabolotny）在 圍場的考察(1898)和伊萬˙斯捷潘諾維奇˙杜琴柯-柯爾巴斯赫柯 (Ivan Stepanovich Dudchenko- Kolbasenko）在蒙古和外貝加爾的考察（1907-1908），探討馬丁榮醫生所持的假說：黑死病 不是當地的地方病，而是由中國華南苦力所傳入的。俄國學者則提出另一假說：黑死病菌是 一種源自動物傳染的瘟疫，主要是西伯利亞的旱獺(土撥鼠)作為帶菌者傳入亞洲內陸。兩種假 說有密切關係。本文最後分析俄國醫學人類學者如何結合兩個互不相容的假說，建構一個跨 地區的黑死病理論模型，而其中喇嘛教則擔當重要角色。這個理論模型建基於錯誤的假設： 旱獺吞吃了感染瘟疫的朝聖者和商人的天葬屍體。本文作者則認為是人類早把瘟疫傳染給旱 獺。

AUTHOR

CHRISTOS LYNTERIS

Christos LYNTERIS has received his MA and PhD in social anthropology at the University of St Andrews, and is currently senior research associate at the Centre for Research, Arts, Social Sciences and Humanities at the University of Cambridge. He is the principal investigator of the European Research Concil-funded 5-year project Visual Representations of the Third Plague Pandemic. He has published The Spirit of Selflessness in Maoist China: Socialist Medicine and the New Man (2012) and several articles on the history of plague in China. CHRISTOS LYNTERIS a obtenu sa thèse de doctorat en anthropologie sociale à l’Université St Andrews. Il est actuellement chercheur au Centre pour la Recherche, les Arts, les Sciences Sociales et les Humanités à l’Université de Cambridge. Il est le porteur principal d’un projet ERC (European Research Council) de cinq ans : Visual Representations of the Third Plague Pandemic (2012). Il a publié The Spirit of Selflessness in Maoist China : Socialist Medicine and the New Man ainsi que plusieurs articles sur l’histoire de la peste en Chine.

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II. Épreuves de souveraineté Tests of Sovereignty

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Measures against Epidemics during Late 18th Century Korea: Reformation or Restoration? Mesures contre les épidémies au xviiie siècle en Corée : réforme ou restauration ? 18세기 후반 조선 국왕 정조의 홍역에 대한 대응 : 개혁인가, 복구인가 ?

Dongwon Shin

Introduction

1 This article examines the nature of the national policies implemented by King Yi San (King Jeongjo; r. 1776-1800), to control hongyeok, literally “red epidemic,” presumed to be measles in contemporary medicine, which was seen as the most fearful pediatric contagious disease during the Joseon Dynasty (1392-1910) in the 17th-19th centuries. The disease was called hongyeok, because a red rash developed all over the body, and it was also known as majin (hemp seed pox) because the rash resembled hemp seeds, which are even smaller than sesame seeds. Along with duchang (smallpox) and another disease vaguely classified as a yeok “pestilence,” hongyeok became established as one of the three most common and most widely spread epidemic diseases. Terrible hongyeok epidemics would strike in cycles of 10-20 years from the mid-17th century onward. The first great outbreak was reported in 1668 and several hundred thousand people lost their lives to the disease in 1707, while the number of dead amounted to 10,000 in Seoul alone in 1730. The great epidemics of hongyeok which had killed more than ten thousand people in 1752 and 1775 were deeply engraved on the minds of contemporaries including King Jeongjo.

2 Yi San, regarded as a reformer king, reigned during the latter half of the Joseon Dynasty. On his enthronement, he established the Royal Library and Archives, where countless documents from home and abroad were collected and where he employed a great number of talented scholars. He continued the policy of impartiality implemented by his predecessor to reduce the ill effects of the chronic power struggles

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between the nation’s political factions. He also started reform in diverse fields including agriculture, commerce, the military, and welfare, notably establishing “The Code for Famine Relief” (1783). He also made unprecedented attempts to obtain information from his subjects, and sought the advice of ministers of state, scholars and provincial administrators, on matters relating to national governance. This course of action, which would later include the “Royal Admonitions Recommending Agriculture and Seeking Agricultural Manuals” (1799), will be examined in detail in the present study.1

3 Early signs of an outbreak of hongyeok in the fourth month of 1786, 11 years after the previous epidemic, caused King Jeongjo to react. The methods he used to implement reforms throughout his reign were also evident in the national plans to control hongyeok. Drawing on different types of sources, we will shed light on the king’s perceptions of this epidemic disease and on the policies he implemented to control it. The king’s instructions and their implementation by the various government offices can be traced through the Jeongjosillok [Annals of King Jeongjo] and Ilseongnok [Records of Daily Reflections], which are very detailed daily logs. In addition to these sources that come from the central administration, there are also diary records from the civilian population such as the Heumyeong [Admiration for Excellence], the diary left by Yu Man-ju (1755-1788), who belonged to a prominent family in Seoul, the city in which the royal palaces were located; and the Ijaenan’-go [Rough Drafts of Master Ijae], the diary left by Hwang Yun-seok (1729-1791), who had just arrived in Seoul to work as a petty government official. These diaries, partly written during the epidemic, serve as alternative sources, offering an insight into how the central measures ordered by the monarch were actually implemented and how they were perceived by the population. By reviewing the interrelations among these records, the present study seeks to deepen our understanding of the national plans against, and civilian responses to, the 1786 hongyeok epidemic. It will thereby clarify King Yi San’s response to the epidemic which also provided him with an opportunity to clearly demonstrate his commitment to protecting and promoting the people’s well-being through good governance, and to frame himself as a Confucian benevolent ruler.

The implementation of a system of thorough medical measures

4 On day 12 of the fourth month, Yu Man-ju heard the Chief Minister reporting: “According to reports, the temporary symptoms are urgent and strange.” The following day (the fourth month 13), he wrote in his diary: “hongyeok patients were found in the upper and lower servants’quarters attached to my house.” On day 14 of the fourth month, at court, Chief Royal Secretary Yi Gyeong-yang proposed the preparation of medical measures: In recent days, hongyeok has spread throughout the capital and the provinces, but the simple and ignorant populace is not aware of formulas suitable for the disease. In terms of the court’s obligation to show solicitude, there must be measures to relieve and save the people. In my opinion, it would be good to have the Medical bureau and the Public Dispensary devise prescriptions for suitable formulas and to promulgate them throughout the provinces.2

5 King Jeongjo ordered the court to discuss such measures, and, on day 20 of the fourth month, 6 days later, the results of the court’s discussions were reported to the

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monarch. First, the point was raised that it was not appropriate for the Medical bureau (Jeonuigam) and the Public Dispensary (Hyeminseo) to devise the prescriptions for formulas and dispatch them to the provinces.3 The following reasons were invoked: there were not yet any reports from the provinces demanding measures against hongyeok; furthermore, as hongyeok was a disease that changed over time and with the seasons, and as living conditions and the people themselves differed from region to region, if people were taking medicine sent from Seoul “without being able to adapt them according to the symptoms,” harm would result instead.4 Consequently, measures against hongyeok were limited to the capital and were assumed by the Government of Seoul. King Jeongjo issued the instruction that when there were appeals from those who were too poor to obtain medicine on their own, regardless of whether they were civil or military officials, commoners, or outcasts, the Medical bureau or the Public Dispensary was to dispatch medical doctors and provide medicine. Together with such measures, he gave 27,000 ansinhwan pills, which were pharmaceutical preparations for the royal household, to diverse offices and structures within the palaces so that they could be distributed widely. He also issued an order instructing that programs for the systematic implementation of measures against hongyeok were to be discussed, created, and submitted by the various government offices, including the Medical bureau, Public Dispensary, and Government of Seoul.5 The fact that King Jeongjo ordered the provision of no fewer than 27,000 ansinhwan pills, which required many costly medicinal ingredients, was unprecedented and demonstrates that the king’s measures were not mere posturing. In addition, the instructions to create operational programs expressed the will to respond to hongyeok by going beyond earlier practice.

6 On day 20 of the fourth month, according to King Jeongjo’s instructions, the Medical bureau and the Public Dispensary, the two structures responsible for treating hongyeok, prepared and submitted “A Program for the Provision of Relief and Treatment for hongyeok” consisting of the following articles: 1. 1.The areas assigned to the Medical bureau and the Public Dispensary: areas to the west of large roads in West Ward, North Ward, and Center Ward are assigned to the Medical bureau; and those to the east of large roads in East Ward, South Ward, and Center Ward are assigned to the Public Dispensary. 2. The dispatch and activities of medical doctors: the Medical bureau and the Public Dispensary each are to select three medical doctors skilled in the medical art, who then are to work all day at either office, inquiring about the symptoms in mild cases and paying visits, making examinations, and providing prescriptions and in serious cases. 3. The objects and documentation of the provision of medicine: Medicine is to be provided only to the poor. Doctors’home visits and the provision of medicine are to be recorded in documents. 4. The promotion of the monarch’s ordinances and “A Program for the Provision of Relief and Treatment for hongyeok”: The Government of Seoul is to translate these into both written classical Chinese and han-geul [Korean Script] and to post them in villages. Upon the discovery of even a single person unaware of them, the officials in charge are to be held accountable. 5. The preparation of medicine including the necessary pills and decoctions: First, medicine is to be prepared from the funds of the Medical bureau and the Public Dispensary, and sufficient quantities are to be separately made up by the Office of Relief Works. 6. The prevention of dishonesty in the provision of medicine: When those who are not poor have received medicine through pretense, they are to be punished severely. In the case of

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patients, they are to report to government offices in advance and to provide confirmatory seals, which are to be used later as the grounds for receiving medicine when it is needed. It is because this measure is a very rare favor. 7. Compensations for medical doctors: In the case of medical officials who do not receive officials’salaries, provisions and food are to be provided according to “Guidelines on the Provision of Relief and Treatment for Infectious Diseases” of the Office of Relief Works. 8. The reporting to superiors of documents on the provision of medicine: The medicine provided by the Medical bureau and the Public Dispensary is to be recorded every day, and statistics on the quantity used and the stock for 5 days are to be reported to the director. 9. The securement of horses solely for doctors’ home visits: When medical officials are to pay home visits, the Board of War is to prepare one post horse each at the two post stations of Cheongpa Station and Nowon Station and even to supply provisions, thus having the officials ready day and night at the two medical offices. 10. The recording of hongyeok patients: The number of cases in which patients have been examined and the symptoms have been discussed, the number of pills and packages of medicine provided, and the number of cases in which medicine has not been used are to be recorded in detail, summarized, and reported at five-day intervals. 11. The permission to carry out private examinations by the medical doctors employed: When the medical officials dispatched have visited and attended to patients from the past, they are not to stop the private examinations due to the present work. However, they are not to use horses for official duties and are to be held accountable when they neglect their duties on the excuse of such private examinations. 12. The readiness of medical doctors: Because patients may arrive when medical officials from the Medical bureau or the Public Dispensary are on home visits, the latter are not all to be away at the same time, with one out of three medical officials standing by in turn. In addition, those who have been discovered outside these medical offices for reasons other than examining patients are to be punished severely.6

7 The Program for the Provision of Relief and Treatment for hongyeok thus encompassed the selection of the government offices for the treatment of hongyeok, the duties and tasks to be assumed by the medical doctors’, the provision of medicine, the establishment of financial sources for the medicinal ingredients, support for the doctors’home visits, the promotion of the project, and the completion and reporting of documents and statistics. Put in modern terms, it was tantamount to the construction of an emergency medical relief system. Problems were revealed after only a few days. According to the first reports, submitted on day 27 of the fourth month, five days after the implementation, “During the five days, packaged medicine was provided in only several dozen cases and pills were provided to only several individuals.”7 This did not conform to the original plan to make extensive medical visits and to save the lives of the populace. On investigation, it turned out that patients were not always examined by medical officials immediately, due to the procedure of having to be certified as patients at government offices. Suspect, too, was the negligence of medical officials at the Medical bureau and the Public Dispensary who were reluctant to work overtime. Furthermore, in one report, a number of medical officials gave the excuse of outside examinations, for not carrying out measures against hongyeok. Consequently, King Jeongjo stated and instructed, “The number of times that patients have been visited, examined, and inquiries made about their diseases likewise is negligible. Where, then, is the original intention for appointing medical doctors and preparing post horses? Once again admonish the two medical offices of this intention.” At the same time, he

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ordered the abolition of the patient registration system. Severely criticizing these government offices’superficial execution of the measures against hongyeok, the monarch strongly urged them to manage the measures properly.8

8 Following King Jeongjo’s order that reports were to be submitted every 5 days, reports on the number of patients and those treated and the provision of medicine were submitted up to 13 times. Thanks to such reports, specific statistics on the number of patients are available.9

9 Total number of cases examined and treated: 6,689 cases (Palace Medical bureau 2,232, Public Dispensary 4,457). Outpatients: 93.3%, doctors’home visits: 6.7%

10 Total number of hongyeok patients: 8,174 individuals (male children – 4,766 (58.3%), female children – 2,714 (33.2%), male adults – 349 (4.3%), female adults – 345 (4.2%)

11 Hongyeok peaked between the day 27 of the fourth month and day 2 of the fifth month, immediately after the first reports. It decreased considerably by day 19 of the sixth month, and then decreased gradually, to be eradicated around day 29 of the sixth month. In addition, as befits a pediatric infectious disease, most of those diagnosed as having the disease were children. However, there were no statistics on the number of deaths.

12 It is possible also to confirm the provision of medicines: 5,363 prescriptions were provided, 7,781 packages of medicine, 4,547 ansinhwan pills, and 825 ox bezoar unguent pills were distributed. Ansinhwan and ox bezoar unguents were among the very costly medicines bestowed on officials and female attendants close to the king on year-end sacrificial rite days and their provision to the populace during times of infectious diseases was unprecedented. Initially, medical officials at the two medical offices tried to avoid dispensing this medication, but the medicine was provided as instructed after admonitions by King Jeongjo, who completed this unprecedented project, making use of his own personal wealth.

An unprecedented royal request that remedies against hongyeok be sought throughout the country

13 On day 22 of the fourth month, along with the proclamation of “A Program for the Provision of Relief and Treatment for hongyeok,” King Jeongjo decreed that “Skilled doctors’treatments against hongyeok [were] to be obtained from Seoul and the provinces.”10 This, too, was unprecedented. It was usual for medical books or prescriptions prepared by royal doctors or medical officials to be transmitted downward to the people;11 but this was the first time that formulas would be presented from the people to the royal court. King Jeongjo’s country-wide request to obtain effective remedies from all his subjects expresses the monarch’s deep concern about the spread of the disease. This request also reveals the king’s understanding of the disease: In general, the outbreak of hongyeok is wholly due to the auxiliary climatic factors of the central movement, and the methods of treatment are not identical, and because the symptoms are already disparate, the ways of applying medicine differ likewise. Since days of yore, medical practitioners well-versed in the medical art have put evolutive phases and climatic factors first without fail, creating, before the outbreak of hongyeok, prescriptions to be used widely or creating, after the outbreak of hongyeok, and disseminating among the entire populace a single prescription by

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examining the annual fortune and taking the seasons into consideration. For hongyeok this year, too, is of a kind of evolutive phase and climatic factor, would not there be, among the countless in Seoul and the provinces who make a living with the medical art, ones such as these and others with such prescriptions?12

14 As this passage highlights, King Jeongjo shared the view that hongyeok stemmed from the five evolutive phases and six climatic factors. In other words, he felt it was due to the auxiliary climatic factors in the universal central movement that hongyeok broke out in years such as the imsin (in Chinese, Renshen) year (1776) and the byeong-o (in Chinese, Bingwu) (1786). As King Jeongjo mentions, past and contemporary medical practitioners were deeply concerned with the periodicity of hongyeok, which in its early stages, was reported as generally spreading in 10-year or 12-year periods. Today, such a phenomenon is explained in terms of herd immunity theory (community immunity). After an epidemic, among survivors, those who have been ill acquire immunity and consequently the number of carriers necessary for a new epidemic is small, thereby preventing an epidemic for some time. However, newborn children have no immunity and as the number of children born after the epidemic increases so does the possibility of a new outbreak, and this process is repeated subsequently. During the 18th century, people viewed the disease’s periodicity as being related to the heavens, or to the movement of the twelve earthly branches (sib-iji in Korean, shierzhi in Chinese) and the ten heavenly stems (sipgan in Korean, shigan in Chinese). In their view, each heavenly stem and earthly branch corresponded to one of the Five Phases (wood, fire, earth, metal, and water) and to one of the six climatic factors (wind, cold, heat, dampness, dryness, and fire), and, as the ten heavenly stems and the twelve earthly branches went in circles and alternated places, the rise and fall of a particular force changed. Contemporaries thus believed that the forces affecting the human body continuously changed during such cycles and, as a result, specific diseases developed more easily in specific years. If one could understand this principle, they claimed, it would then become possible to prepare formulas that would control a particular force. To King Jeongjo’s thinking, because the evolutive phases and the climatic factors were circulatory by nature, it was thus possible to prepare formulas in advance, and then tailor them according to the particular force influencing the outbreak, and use them when the disease struck.

15 Underlying King Jeongjo’s measure of searching countrywide for doctors well-versed in the medical art and formulas, was the idea that, due to inexperience, the medical officials in Seoul were unable to present effective formulas against hongyeok. As already noted, hongyeok was a disease that was known to disappear after cycles of ten or more years. Research on this disease was usually neglected by medical doctors. In Magwahoetong (A Comprehensive Treatise on the majin, 1797), Jeong Yag-yong explained why: It is sad. It has been a long time since the sick have lacked medical doctors. Although this holds true of all diseases, it is even more severe in the case of hongyeok, and what may the reasons be? Those who make their living as medical doctors do so to make a profit. As there is usually only one outbreak every twelve years or so they don’t bother to learn how to treat hongyeok, because there is no money in it. It is shameful that those who make a living from medicine do not study this disease, and also shameful to treat someone with hongyeok as it is, alas, cruel to use medicine by conjecture and thus to cause someone’s death.13

16 King Jeongjo’s perception was identical. He therefore issued an order targeting the entire population: “If there are those who are well-versed in evolutive phases and

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climatic factors and have created formulas, they are to submit [the formulas] to headquarter towns regardless of whether they are aristocrats or provincial rank- holders, whether their formulas are ancient or modern, and [the formulas] are to be transmitted to government offices in Seoul.”14 Public notices posted in Seoul and dispatched to the provinces reported: Scholars in Seoul and the provinces who make a living with the medical art are ashamed to boast of themselves, and the outcasts who have secret formulas find it difficult to present themselves voluntarily. In hindering the transmission of such formulas they are defying the king’s wishes to make enquiries from the populace. At one time in days of yore, lost books were sought and those who found them were bestowed with government posts. If there are good formulas that will allow the populace to enjoy their natural spans of life and are proven to be clearly effective, how would the merits be comparable to those of finding and presenting lost books? 15

17 Only a month or so after the issuance of the order to obtain formulas for hongyeok, the Jingyeokbang (Formula against hongyeok) by Bak Sang-don, a Confucian scholar in Chilgok, Gyeongsang Province without an official title, and formulas submitted by Nam Gi-bok, an aristocrat in Jincheon, North Chungcheong Province, were presented.16 The Medical bureau and the Palace Pharmacy examined them and found that they were Chinese formulas against hongyeok. Bak Sang-don’s formula was judged more reliable and therefore was chosen, printed and dispatched to each province on the fifth month 29.17

18 King Jeongjo’s requests for plain counsel from his subjects are measures unseen during the reigns of earlier monarchs. Over ten years later, he would again request scholars nationwide for plain counsel from his subjects regarding agriculture. This method, then, was first used during hongyeok in 1786, for the first time in the history of the Joseon Dynasty.

The expansion of the scope and the strict implementation of the sacrificial rites to the demons of pestilence

19 While we have focused on the monarch’s deep concern in providing medical care to the populace, the first measure against the outbreak of hongyeok was, however, not the medical measures examined above but the performance of sacrificial rites to the demons of pestilence, and to the gods of epidemic diseases. On the 10th day of the fourth month, while the court was pondering measures against hongyeok and ten days before the implementation of medical measures, King Jeongjo ordered the immediate performance of sacrificial rites to the demons of pestilence.18

20 Undocumented up to the Goryeo Dynasty (918-1392), sacrificial rites to the demons of pestilence were institutionalized in 1403, immediately after the foundation of the Joseon Dynasty, on the model of Ming China’s “Ritual System in the Hongwu Era” (1370).19 The “Ritual System in the Hongwu Era” includes the following: (According to the Emperor’s imperial edicts)… Without being offered sacrificial rites, such spirit have no place to rely on so that the spirits condense instead of dispersing and thereby become spirits of the dead. While some dwell in trees and grass, others turn into ghosts, crying out plaintively on moonlit nights and wailing during rainstorms. In general, when they encounter [living] people, they

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desperately long for the bright world, but their spirits are far-off and have nowhere to return to. Whereas the bodies rot, flung down in the streets, the minds anxiously wish for sacrificial rites. Having thus spoken, I cannot hide my sentiments of pity out of sorrow (for the ghosts). I therefore have admonished Confucian scholars across the country and commanded them to hold sacrificial rites according to seasonal sacrificial rites and the tutelary gods of the main areas to preside over (the sacrificial rites).20

21 The objects of sacrificial rites to the demons of pestilence were spirits of the deceased who had not been offered a proper funerary rite. They were believed to turn into vengeful spirits and to cause various disasters, particularly epidemic diseases. In Ming China the tradition of holding sacrificial rites for spirits who had not been offered a proper funerary rites also included folk and Daoist tutelary gods who served to monitor unjust deaths in their respective areas and the good and evil deeds performed by the living. In Ming China, sacrificial rites to tutelary gods were held in the capital, state sacrificial rites to the demons of pestilence were held in provinces, county sacrificial rites to the demons of pestilence were held in cities and major prefectures, and town sacrificial rites to the demons of pestilence were held in lesser prefectures. An altar had been created to the north of the Korean capital and sacrificial rites to the demons of pestilence were performed.21 In the Joseon, regulations on sacrificial rites to the demons of pestilence were established according to Gukjo Oryeui (the Manual of the Five State Rites, 1474, in the 5th year of King Seongjong’s reign). According to these regulations, sacrificial rites to the demons of pestilence consisted of two rites: sacrificial rites to tutelary gods and sacrificial rites to the demons of pestilence. In addition, the altars were placed in the East, West, South, and North of Seoul. The ceremonies included different sequences: first, three days before the sacrificial rites to the demons of pestilence, the rites of announcement were held, where tutelary gods were to be informed at the South Altar of the prospective date of the sacrificial rites. Three days later, the sacrificial rites to the demons of pestilence, namely the main ceremony, were to be held at the North Altar. The spirit tablets of tutelary god were brought in and arranged at the North Altar, facing the South Altar; those of the fifteen kinds of spirits who had not been offered a proper funerary rite, who were lower than tutelary gods, in the divine hierarchy, were arranged below the altar, on the right and left sides, facing one another.22 The fifteen spirits honored those who had died one of the fifteen unjust deaths—in cart accidents, on the battlefield, by drowning, etc. Without these rites, these deceased souls, unable to rest or enter the underworld would become vengeful ghosts, able to infect individuals and communities with contagious diseases.23

22 King Jeongjo sought to strictly implement the ritual system relating to the performance of sacrificial rites to the demons of pestilence. This meant the restoration of all elements originally implemented during the reign of the Ming Emperor Hongwu (Taizu) but not continued in the Joseon dynasty. According to the king Jeongjo’s orders, incense was to be collected on a selected day one or two days before the sacrificial rites to the demons of pestilence; tutelary gods were to be informed without fail; after performing the rites of announcement to tutelary gods, hitherto omitted, the sacrificial rites to the demons of pestilence, hitherto performed only at the altar to the north, were to be performed in the four wards and the center of Seoul; and all provincial towns likewise were to hold the sacrificial rites.24 The monarch then instructed the composition of ritual invocations by the Yebu (Office of Royal Decrees) to be used as

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follows; by the state ritual officiators who presided over the sacrificial rites in the capital, by senior statesmen who were to be dispatched in the case of altars to tutelary gods and by officials with the 4th and higher court ranks who were to be selected and dispatched in the case of altars to the demons of pestilence.25 In addition, King Jeongjo personally composed ritual invocations such as the one below: While there are a hundred gods in the realm, our tutelary god is placed at the head, and only it can command disasters and auspices. (It turns disasters into auspices.) Though sinister energy has been swept away widely and the epidemic disease has been driven back (all the times), putting around thousands of miles, how was the stirring up of eruptions in people made to start (itself) in spring? When demons of ill-health seized the fire, many of the people fell ill. While it must be guaranteed that there are no disasters of deaths, how is it that the people are gradually infected? If men and gods are to be seen equally, gods oversee the lives of my people, (they say that I am the lord of taking charge of lives of people) the range of Mt. Mang [a mountain in China often used as a figure for burial grounds] extends far, and widely watches over new lands. Lastly, forming the netherworld, leads every (frustrated) spirit to return to supreme harmony. To offer sacrificial rites with clean offerings, I have chosen an auspicious day (morning) and thus call out loudly. It is a wide and distant field, and I prompt them to arrive from all directions and to eat and drink their fill, and there are ceremonial vessels made of earth and wine jars made of baked earth. For, last night, a great rain fell and cleanly washed away the sinister energy and pestilence, allowing them to enjoy longevity. Save my people for years to come.26

23 Whether this ritual invocation to the demons of pestilence is specifically related to hongyeok remains uncertain. As the invocation assumes the form of rites to the demons of pestilence at the altars in the four suburbs, and not only at the North altar, it presumably dates from this or a later period. It is possible to read in this ritual invocation King Jeongjo’s wish, as national ruler, to resolve the disaster that had befallen the country. Indeed, it was rare for a monarch personally to compose a ritual invocation. Only the ritual invocations to the demons of pestilence composed by King Jungjong (r. 1506-1544) are known.

24 In focusing on measures to restore the old forms of the sacrificial rites to the demons of pestilence, one must not overlook the fact that King Jeongjo’s performance of sacrificial rites to the demons of pestilence with respect to hongyeok reflected innovation: this was the first time that sacrificial rites to the demons of pestilence were held for the epidemic disease known as hongyeok. The monarch stated: “Because, out of cases from the past there are but few that can be used precisely as authorities, there is no reason not to establish the system after consideration now.”27 Originally, the epidemic diseases for which sacrificial rites to the demons of pestilence were held included pestilence onyeok (warm epidemic), and dangdokyek (poisonous plague from Tang). Neither smallpox duchang nor hongyeok, characterized by abnormal symptoms on the skin, had been the object of sacrificial rites to the demons of pestilence. However, King Jeongjo included hongyeok among the objects of sacrificial rites to the demons of pestilence, arguing: “As it is said that there is a very severe outbreak of hongyeok now, the people must be concerned about infection. How, then, can one sit and just wait until the disease disappears completely? The sacrificial rites praying for the eradication of hongyeok cannot wait a moment longer.”28 This provides us a glimpse of the monarch’s style of governance; in order to protect his people, he went against convention.

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How did the civilian population consider the measures against hongyeok?

25 The measures taken against the hongyeok epidemic in 1786 highlight how King Jeongjo made the provision of costly medicinal ingredients to the impoverished populace possible with money from his personal wealth. In addition, he established thorough guidelines for the hongyeok prevention project, thus facilitating the hongyeok prevention activities of the Medical bureau and the Public Dispensary. Statistics on diagnosed sufferers were submitted on a strict five-day basis, and at the monarch’s request, efforts were made to acquire the latest medical information countrywide. Likewise, another measure against epidemic diseases, sacrificial rites to the demons of pestilence, was used against hongyeok for the first time in history and held after the restoration of strict adherence to the traditional rituals. How, then, were such measures received by the civilian population? While there are no historical materials that reveal the entire situation, a fragment can be surmised through the contents of Yu Man-ju’s diary Heumyeong (Admiration for Excellence) and Hwang Yun-seok’s diary Ijenan’-go (Rough Drafts of Master Ijae).

26 Both records express interest in the monarch’s issuance of an order to obtain formulas against hongyeok from the farthest reaches of his kingdom. On the very day that this measure was announced, Yu Man-ju recorded in his diary: “Because there has been a great outbreak of hongyeok, the king has issued an instruction for the provision of formulas from skilled doctors in Seoul and the provinces” (the 22nd day of the fourth month).29

27 Hwang Yun-seok likewise wrote on the 27th day of the fourth month, three days after Yu Man-ju: “Because there have been great outbreaks of hongyeok in recent days, the king has been concerned and issued an order, far and near, for a wide search throughout the country for secret formulas and recommendations from skilled doctors and their special.”30 This diary shows that the order was promptly transmitted not only to the capital but also to the provinces through the regional administrative network, and, as a result, many formulas were submitted. The countrywide and unprecedented search for formulas launched by the King was of considerable interest at least to scholars, whose participation had been requested by the monarch.

28 These two diaries do not express much interest in the ruler’s other measures. What attracted the attention of these two scholars was the disease’s appearance at the court. On day 3 of the fifth month, 1786, the crown prince, the heir to the throne, began to show symptoms of the disease whose development was recorded with great interest in these diaries, almost hour by hour as if in a real-time broadcast. Indeed, in dozens of entries, the two diaries vividly record the progress of the crown prince’s illness until his death. News on the crown prince’s contraction of hongyeok and death were thus transmitted to the residents of the capital moment by moment. In fact, the king, queen, and crown prince were the object of constant public scrutiny, not least because their complete recovery from illnesses were often followed by measures of favor such as the remission of taxes and the release of minor offenders or by holding special state service examinations. Yu Man-ju’s diary precisely records that extraordinary examinations had been planned in Seoul (the 7th day of the fifth month), in celebration of the crown prince’s hoped for recovery.31

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29 Although King Jeongjo made unprecedented efforts, the provision of costly medicines and the strict procedures for the examination and management of patients went unnoted by both Yu Man-ju and Hwang Yun-seok. While there were hongyeok patients in Yu Man-ju’s household, they were unaffected by the measures taken by the court because the family was not poor. To treat hongyeok patients in the family including his own son, Yu Man-ju personally visited a private medical doctor and purchased medicine at a pharmacy. As for Hwang Yun-seok, because he was away from his family, was alone in Seoul and had not contracted hongyeok himself, King Jeongjo’s medical measures did not apply to him, even if his diary bears testimony that he was very anxious that young children in his family might contract the disease.

30 Hwang Yun-seok’s diary contains another important narrative that sheds light on an outcasts’perception of hongyeok. On the 13th day of the fifth month, the day after the crown prince’s death, a slave known as Jeong came to the capital from the diarist’s native town of Heungdeok. Regarding the deaths of those of noble births, this man explained his views: As I was traveling to Seoul and passing by Seonghwan Post Station, I heard that there were cases of baby hongyeok. Since spring, there has been smallpox in Seoul, then hongyeok immediately afterwards, and many died because, after hongyeok had been cured, there still remained great pain due to heat and roundworms among the people. In the world, those who could not afford medicine were happy, while the high officials who had a lot of medicine deteriorated so that countless died violently from remaining symptoms such as strong headaches as if the head was struck, extreme fits, blank stares, and mere words. With this illness, it was possible to save lives only with a common distilled liquor, sojo [folk alcohol drink] and dried meat. (13th day of the fifth month.)32

31 The slave’s words saying that among the public, those who did not get medicine actually were fortunate, while the high officials who had much medicine, met with ruin are paradoxical in a sense. The idea that having a good stock of medicine is not always helpful and that only sojo and dried meat and fish are sufficient reflect the idea that while they might (always) be deficient in medicine, their lot, need not be pitiable. It is difficult to find the voices of other slaves in Joseon’s medical records that would confirm Jeong’s viewpoint. An account like Joeng’s was a very rare case since most records of the time were from the elite class. However, it suggests that opinion may have been divided on the benefits of the monarch’s actions, and notably on his bestowal of costly medicine on his people.

32 Neither of the two diaries mentions the implementation of the strict sacrificial rites to the demons of pestilence, for which King Jeongjo expended considerable and unprecedented effort. While, as a ruler, he attached much significance to the reestablishment of more complete rites than had been practiced under more recent monarchs and the performance of sacrificial rites to the demons of pestilence with respect to hongyeok, the acts do not seem to have greatly impressed scholars and the populace. The sacrificial rites to the demons of pestilence are likely to have been perceived as routines performed by the king or regional magistrates. In other words, they failed to attract attention because they were changes, no matter how considerable, within routines. Rather, the citizens of Seoul, like Hwang Yun-seok, had another perception of the causes of the outbreak of the epidemic: “The diverse symptoms of hongyeok are thus severe because people relocated graves in March a taboo in the old days, but do not abide by it now” (Hwang Yun-seok, day 27 of the fourth month).33

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While spirits who had not been offered proper funerary rites had become established as symbolic entities in routines, the citizens of Seoul were considering the more direct reason that the disease was the work of vengeful spirits due to the violation of a taboo and the relocation of graves.

Conclusion: innovation or restoration?

33 The 1786 hongyeok epidemic passed without great loss of life. Whether this was due to King Jeongjo’s measures against hongyeok is questionable. Although it is difficult to determine the actual reasons, the disease weakened in Korea after 1775 and there were no longer terrible epidemics as in the past.

34 Two coexisting views on the causes of these epidemics can be seen in King Jeongjo’s actions. One came from the medical theory of the five evolutive phases and six climatic factors. As diseases were believed to assume periodicity according to the movement of celestial forces, these epidemics could be countered by understanding the motions of the cosmos and preparing suitable formulas in advance. Based on such thinking, the king issued orders to obtain formulas from around the country. The second came from the longstanding beliefs about the role of demons in the spread of epidemic diseases: vengeful spirits who had not been offered proper funerary rites were believed to cause epidemic diseases. As a consequence of this perception, epidemic diseases could be resolved by placating those vengeful spirits. King Jeongjo expanded this thinking to include the disease known as hongyeok and sought to obtain the desired effect by restoring a stricter observation of the traditional rituals devoted to appeasing these spirits. This epidemic disease, which, in the eyes of the monarch, could be explained by natural and supernatural forces, at the same time, provided him the opportunity to demonstrate his ability to embody the most esteemed values of Confucian political thought and to shape himself as a benevolent ruler by excellence, a condition for authority.

35 As mentioned earlier, King Jeongjo sought to demonstrate the proper norms of governance in all fields. To him, this signified the realization of the Confucian ideology as shown by ancient sages. The epidemic gave him the opportunity to reactivate these norms in the medical field, which, as this contribution shows, consisted in restoring the ancient sacrificial rites to the demons of pestilence as well as implementing emergency relief measures including the bestowal of costly medicine and a strict control over medical administration. The tradition of dispatching medical doctors or medicine to places plagued by epidemic diseases had been implemented since the early years of the Joseon Dynasty and was also stipulated in the legal codes. In this respect, it is possible to say that King Jeongjo’s methods were not entirely new. Nevertheless, whether such actions led to the actual provision of medical aid or remained mere words depended on who the monarch was. The case of King Jeongjo seems exceptional since his measures did not stop at formal measures but rather encompassed the exploration of other methods not attempted by previous rulers. His expansive politic did not stop at the provision of medicine to the populace through government medical structures such as the Medical bureau and the Public Dispensary, but also included making costly medicines such as ansinhwan. This spirit of selfless dedication is also evinced by the operation of an emergency system using post horses, a strict 5-day report system, direct and unceasing concern for medical administration even in the face of his own

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son’s death; and the unprecedented step of making direct inquiries to his ministers and people for formulas against hongyeok. All of these measures are difficult to find in the policies of earlier monarchs and helped grant King Jeongjo, like the earlier King Sejong (r. 1418-1450) from the first half of the Joseon Dynasty, the status of an enlightened monarch. Similarities can also be confirmed in the case of the implementation of sacrificial rites to the demons of pestilence, which were complementary responses to hongyeok. Implemented as a measure against epidemic diseases since the first years of the dynasty, sacrificial rites to the demons of pestilence were not in themselves new. However, King Jeongjo did not follow established practice. Instead of allowing the procedures of sacrificial rites to the demons of pestilence to be implemented in a reduced form, he ordered that the full ceremonies stipulated by the Ming Ritual System in the Hongwu Era (Hongwu Lizhi) were strictly followed. In contrast to his forebears, he boldly included hongyeok as an object of the sacrificial rites which had not previously been encompassed by sacrificial rites to the demons of pestilence. Moreover, he personally composed ritual invocations to the demons of pestilence, something that was uncommon for earlier monarchs. Through these measures, King Jeongjo clearly demonstrated his commitment to protecting and promoting the people’s well-being, framing himself as a Confucian benevolent ruler.

36 Finally, do the measures taken against hongyeok during the of King Jeongjo’s reign qualify as being innovative or reformative? When seen macroscopically, the measures against hongyeok taken by the ruler were in part inherited and yet in other areas far exceeded previous methods. Scholars who seek to find modernity in King Jeongjo’s rule will perhaps call this an “innovation.” Innovation appears clearly in the unprecedented provision of medicines and the unprecedented acquisition of information, and even in the extension of the religious rituals against epidemics to include new epidemic diseases such as hongyeok. To render measures according to the theory of ghosts more thorough, old institutions were revived and extended. King Jeongio’s “innovation” encompassed not only the implementation of new ideas, but also the restoration of underlying traditions.

BIBLIOGRAPHY

Gugyeok Joseon wangjosillok 國譯朝鮮王朝實錄 (Korean Translation of the Annals of the Joseon Dynasty) (1993). Seoul, Sejong saeop ginyeomhoe.

Gugyeokilseongllok 國譯日省錄 (A Korean Translation of Records of Daily Reflections) (2001). Seoul, Minjok munhwa chujinhoe.

HWANG Yun-seok (1994). Ijaenan’go 頤齎亂藁 (Rough Drafts of Master Ijae). Seoul, Han’guk jeongsin munhwa yeonguwon.

JEONG Yag-yong (1937-1938). Magwa hoetong 麻科會通 (A Comprehensive Treatise on the majin) Yeoyudang jeonseo 與猶堂全書 [All Books of Yeoyudang], Keijō, Shinchōsen-sha.

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MUHN Joogn-yang (2005). Joseon Hugiui ‘Surihak’ 朝鮮 後期의 水利學 (The Hydro-Agricultural Knowledge in the Late Choson Korea). P.H. Dissertation, Program of History of Science and Philosophy, Seoul National University.

SHIN Dong-won (2004). Hoyeolja, Joseon-eul Seupgyeokhada: Mom gwa Uihak-ui Han-guksa 호열자 조선 을 습격하다 몸과 의학의 한국사 (Cholera Raids Joseon: A Korean History of the Body and Medicine). Seoul, Yeoksabipyeongsa.

YI Uk (2009). Joseon sidae jaenan gwa gukga Uirye 조선시대 재난과 국가 의례 (Disasters and State Rites during the Joseon Dynasty). Seoul, Changbi.

YI San (1998). Gugyeok Hongjae jeonseo 國譯弘齋全書 (A Korean Translation of All Books of Hongjae). Minjokmunhwachujinhoe.

YU Man-ju (1993). Heumyeong 欽英 (Admiration for Excellence). Seoul, Seoul Daehakyo Gyujang’gak.

APPENDIXES

Glossary

Ansinhwan 安神丸 Bak, Sang-don 朴尙敦 Byeongo 丙午 Bingwu (in Chinese) Dangdokyeok 唐毒疫 Duchang 痘瘡 Goryeo (Dynasty) (918-1392) 高麗 (王朝) Gukjo Oryeui 國朝五禮儀 Gugyeok ilseongnok 國譯日省錄 Heumyeong 欽英 Hongwu Lizhi 洪武禮制 Hongyeok 紅疫 Hwang Yun-seok 黃胤錫 Hyeminseo 惠民署 Ijaenan-go 頤齎亂藁 Imsin 壬申 (Renshen, in Chinese) Jeonuigam 典醫監 King Jeongjo 正祖 King Sejong 世宗 Jeongjosillok 正祖實錄 Jinyeokbang 疹疫方 Joseon (Dynasty) (1392-1910) 朝鮮 (王朝) Majin 麻疹 Magwa hoetong 麻科會通 Nam, Gi-bok 南紀復 Onyeok 瘟疫 Sipgan 十干 (shigan, in Chinese) Sib-iji 十二支 (shier zhi, in Chinese) Sojo 燒酒

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Yebu 禮部 Yeojemun 厲祭文 Yeok 疫 Yu Man-ju 兪晩柱

NOTES

1. Muhn Joong-yang 1995: 117-136. 2. Gugyeok Joseon wangjo sillok 1993: 564. 3. In 1109, in imitation of the Song Chinese tradition of treating the illnesses of the populace in which the “monarch bestows medicine as a virtuous deed for the populace,” the Hyeminseo (Public Dispensary) was established to provide medicine to the inhabitants of the capital. This ideology of providing medical services to commoners was subsequently transmitted to the Joseon Dynasty, founded in 1392. The Joseon Dynasty established the Jeonuigam (the Medical bureau) separately from the public Dispensary, for the higher ruling class. 4. Gugyeok Joseon wangjosillok 1993: 565. 5. Gugyeok Joseon wangjosillok 1993: 565. 6. Gugyeok Joseon wangjo sillok 1993: 565. 7. Gugyeokilseongllok 2001: vol. 57, 325-356. 8. Gugyeokilseongllok 2001: vol. 57, 325-356. 9. Gugyeokilseongllok 2001: vol. 57, 325-326; vol. 58, 27, 37, 72, 117-118, 159, 213-214, 260-261, 304-305. 10. Gugyeokilseongllok 2001: vol. 57, 304-306. 11. Shin, Dongwon 2004: 53-54. 12. Gugyeokilseongllok 2001: vol. 57, 304-306. 13. Jeong Yag-yong1934-1938: 286-413a. 14. Gugyeokilseongllok 2001: vol. 57, 304-306. 15. Gugyeokilseongllok 2001: vol. 57, 304-306. 16. Gugyeokilseongllok 2001: vol. 57, 325-326. 17. Gugyeokilseongllok 2001: vol. 58, 191-201. 18. Gugyeokilseongllok 2001: vol. 57, 244-246. 19. Yi Uk 2009: 301-306. 20. Yi Uk 2009: 307. 21. Yi Uk 2009: 307-311. 22. Yi Uk 2009: 305. 23. Yi Uk 2009: 299-386. 24. Gugyeokilseongllok 2001: vol. 57, 244-246. 25. Gugyeokilseongllok 2001: vol. 57, 244-246. 26. Yi, San 1998: a_262_328c. 27. Gugyeokilseongllok 2001: vol. 57, 244-246. 28. Gugyeokilseongllok 2001: vol. 57, 244-246. 29. Yu, Man-ju 1993: vol. 6, 213. 30. Hwang, Yun-seok 1994: vol. 7, 216. 31. Yu, Man-ju 1993: vol. 6, 222. 32. Hwang, Yun-seok 1994: vol. 7, 258. 33. Hwang, Yun-seok 1994: vol. 7, 216.

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ABSTRACTS

This article examines the nature of the policies implemented by King Yi San (King Jeongjo; r. 1776-1800) to control hongyeok [plague with red spots on the body], presumed to be measles in contemporary medicine, which was seen as the most dangerous pediatric infectious disease during the three last centuries of the Joseon Dynasty (1392-1910). Drawing on different types of sources, the Jeongjosillok [Annals of King Jeongjo] and Ilseongrok [Records of Daily Reflections] and on diary records from the civilian population, it sheds light on the conceptions of the causes of this epidemic disease at that time and examines to what extent the King Jeongjo’s response to this crisis—the implementation of strict and unprecedented medical regulations and the reestablishment of (forgotten) religious rituals—were particular and how they were received by the common populace. Finally, it shows how this epidemic gave the king the opportunity to embody, more than any of his forebears, the figure of both a reformer and a benevolent Confucian ruler.

Dans cet article, l’auteur examine la nature des politiques menées par le roi Yi San (Roi Jeongjo, r. 1776-1800) pour maîtriser “l’épidémie rouge” hongyeok [maladie couvrant le corps de boutons rouges], correspondant probablement à la rougeole, considérée comme la maladie pédiatrique la plus dangereuse au cours des trois derniers siècles de la dynastie Joseon (1392-1910). S’appuyant sur des sources centrales comme les Annales du roi Jeongjo [Jeongjosillok] et les Souvenirs des réflexions quotidiennes [Ilseongrok] mais prenant aussi en considération les journaux intimes de certains membres de la société civile, il révèle les différentes perceptions contemporaines de cette maladie épidémique et analyse dans quelle mesure les réponses du roi Jeongjo apportées à cette crise – la mise en place d’une réglementation médicale très stricte et le rétablissement de rituels religieux oubliés – sont nouvelles et comprises par la population. Enfin, l’auteur montre combien cette épidémie fournit au roi l’opportunité d’incarner, plus que ses prédécesseurs, la double figure du réformateur et du souverain confucéen bienveillant.

조선의 국왕 정조 치하(1777-1800) 조선 정부는 역병에 대한 대응이 이전에 비해 커다란 차이를 보였다. 그것은 의료적인 측면에서 뿐만 아니라 종교적인 의료 부분에서도 그랬다. 1786년 홍역 이 유행하게 되자 정조는 정부 의료기관에 유례가 없을 정도의 엄격한 관리를 명했는데, 환자의 집계, 의사의 환 가 방문과 약 제공, 전국에 걸쳐 효과적인 처방의 수집과 정리, 효과적인 처방의 전국적인 보급 등이 포함되어 있었다. 그것은 이전의 조치와 비슷하기보다는 마치 근대 이후의 조치와 비슷한 성격을 띠었다. 이런 조치와 함께 정조는 예조에 명하여 홍역에 대한 여제를 그간 생략된 옛 절 차를 완벽히 복원하여 제대로 거행할 것을 지시했다. 이런 양 측면의 모순적 성격은 정조의 역 병 대책이 근대지향적인 것이었는가, 아니면 옛 유교적 이념의 철저한 복구였는가 ?

AUTHOR

DONGWON SHIN

SHIN Dongwon is professor at KAIST (Korean Advanced Institute of Science and Technology). He works on the history of medicine and hygiene in Korea and published several books including Hohwan, Mama, Cheondu (A History of Concept of Disease, 2013), Heyeolja, JoseoneulSeupgyeokhada: MomgwaUiha-uiHanguksa (A Korean History of the Body and Medicine, 2004) and HankukKeundaiPogeonUiryosa (History of the Modern in Korea, 1997). SHIN Dongwon est professeur au KAIST (Korean Advanced Institute of Science and Technology) en

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Corée. Il travaille sur l’histoire de la médecine coréenne et a publié plusieurs livres, dont Hohwan, Mama, Cheondu (Une histoire du concept de maladie, 2013), Heyeolja, Joseoneul Seupgyeokhada : Momgwa Uiha-ui Hanguksa (Histoire du corps et de la médecine coréenne, 2004) et Hankuk Keundai Pogeon Uiryosa (Histoire des soins modernes en Corée, 1997).

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Epidemic Control and Wars in Republican China (1935-1955) Contrôle des épidémies et guerres dans la Chine républicaine (1935-1955) 民國時期中國境內的戰爭與疫病控制 (1935-1955)

Michael Shiyung Liu

EDITOR'S NOTE

The research has been supported by the National Science Council of Taiwan projects NSC101-2410-H-001-022 and NSC99-2410-H-001-044-MY2.

1 During the second half of the 20th century, the US government and US-based NGOs more than doubled their funding of overseas medical programs, bringing it up to thirty percent of total foreign aid expenditure. There has, however, been little direct study of the role American medical aid has played in building the long-term security, stability, governance, or legitimacy of East Asian countries where adverse health conditions may affect US interests. This article sheds light on American medical aid to China in the turbulent decades of the Sino-Japanese War (1937-1945), the Chinese Civil War (1947-1949), and the subsequent scission of China into two political entities, when the Nationalist government had to face health problems directly linked to armed combat as well as epidemic diseases.

2 Epidemic control was not the leading priority during the Sino-Japanese War (1937-1945). The treatment of the epidemics that swept the country was largely overshadowed by health problems more directly linked to the war. However, the emergency measures and structures implemented during the war, and largely financed by American organizations, were the foundations for epidemic control in the post-war era. Between 1945 and 1952, plague and cholera were endemic throughout China, and over the same period it was estimated that more than one million people were infected with malaria. These “post-war” epidemics which were attributed to the destruction of quarantine systems as well as to the movement of refugees through the country had a

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serious impact on people’s lives and hindered recovery projects put in place by local and regional authorities.2 Controlling these epidemics soon became a common goal uniting Japanese-trained and American-influenced medical professionals in the country.

3 Drawing on archives from the Rockefeller Archive Center (New York),3 Academia Historica and the National Defense Medical Center (NDMC) in Taiwan, and Japan Diet Library, this article aims to portray the challenge of controlling epidemics during the early post-WWII period in China and of reconstructing epidemic control systems in Taiwan from 1949 onward. In addition to focusing on the post-WWII era, it traces the long-term cooperation between Nationalist China and US philanthropic organizations such as the American Bureau of Medical Aid to China (ABMAC) as well as the Rockefeller Foundation and its medical affiliate, the China Medical Board (CMB) prior to 1945. It also assesses the impact of the Nationalist Government’s withdrawal to Taiwan on the rebuilding of epidemic prevention systems in mainland China and Taiwan.

American medical aid in wartime China

4 The motives for reestablishing a public health system in post-WWII China were twofold. One reason was the urgent need to prevent the return of epidemics as a result of long- term war damage. The other was to resume the efforts in public health modernization which had been interrupted by the 1937-1945 Sino-Japanese war. According to Yip Ka- che, the American-oriented medical curriculum as well as the technical approaches of the Rockefeller Foundation were adopted by the majority of the health officials of the Nationalist government during the 1930s as a part of the public health modernization scheme.4 However, there were many obstructions to the ambitious scheme that Americans and the Nationalist government proposed. Yip shows that the agricultural economy was a significant hindrance to the project, since industrialization was a key factor in the development of the American public health system.5 Besides, to most historians of modern China, the military conflict between Japan and China during the period was another major factor delaying the modernization efforts.

5 In mainland China, the Peking Union Medical College (PUMC) and the CMB, both funded by the Rockefeller Foundation, had been major actors in transforming medical and public health systems since the first decade of the 20th century.6 However, in response to the crisis caused by the escalating Sino-Japanese war, expatriate Chinese and alumni from PUMC set up the American Bureau for Medical Aid to China (ABMAC), later the American Bureau for Medical Advancement in China. ABMAC was a philanthropic organization whose sole aim was to assist the medical modernization in wartime China.

6 The Japanese conquest of Manchuria in 1931 was only the first step in what became a much larger campaign to expand Japanese influence in Northern China, a campaign that resulted in full-scale war between Japan and China in 1937. The invasion of China proper began in earnest with “The North China Incident,” a military clash that occurred between Chinese and Japanese troops in 1937 near Beiping (today’s Beijing) in North China. Before “The North China Incident,” the Defense of the Great Wall or Battle of Gubeikou (also known as “Operation Nekka” or “First Battle of Hopei”) took place between January 1 and May 31, 1933 (Map 1).7 Gubeikou, the gateway to Beiping was

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invaded in March 10, 1933 and the battle lasted until May 14. In the first three days of battle, the number of Japanese casualties reached two thousand. During the whole period before the cease-fire agreement on May 31, 1933, at least 620,000 Chinese soldiers died in action. Twice as many died from disease. Infectious diseases such as dysentery, measles, smallpox, and pneumonia were the soldier’s greatest enemies. The cold, poor hygiene, the lack of adequate sanitation, shelter and suitable clothing, the poor quality of food and water, and the crowded conditions were ideal breeding grounds for disease.8 Various estimates exist on the number of casualties inflicted during the Battle of Gubeikou,9 but one common estimate is as follows in chart 1.

Map 1. “The North China Incident”

Source: Michael Lindsay (1945): 173.

Chart 1. Casualty estimates for the Battle of Gubeikou between March 10 and 14

Casualties

Killed Wounded Missing Total

Chinese 6,100 + 24,000 8,000+ 38,100+(est.)

Japanese 2,600- 10,800 6,500- 19,900 +

Source: US, Department of State (1943). Peace and War: United States Foreign Policy, 1931-1941. Washington (D.C.), US, Government Printing Office: 44-52; Michael Lindsay (1945).

7 During the invasion of the North China Plain by Japanese troops, the Chinese government was unable to provide sufficient medical care and PUMC doctors played an important role in caring for both military personnel and the civilians caught up in the conflict.10 Dr. Robert Lim, a physiologist, at the PUMC faculty organized the first

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medical supplies to the field at Gubeikou and secured relief from the International Red Cross. Robert Lim (1897-1969), was born in Singapore and studied medicine at Edinburgh University. He went on to head the PUMC Physiology department from 1926 to 1937.11 With his experience on the frontline in North China and his patriotic spirit, Dr. Lim became chairman of the Army Medical Administration in the Nationalist government’s Military Affairs Commission in December 1937, just before the Japanese invasion of Nanjing.

8 Assistance provided by American funding had been, in part, to run medical schools such as those created in Beijing (1906), Jinan (1909), Chengdu and Changsha (1914), which were fully supported by American on-going donations from the Rockefeller Foundation.12 However, assistance provided by American funding was not only for the day-to day running of the medical schools; it also took the form of assistance in times of acute crises, such as when the Yellow River was flooded in 1938. Following the outbreak of the war in 1937, the Japanese army marched rapidly into the heart of Chinese territory. On June 6, 1938, they captured Kaifeng, the capital of Henan, and threatened to take over Zhengzhou, at the junction of the arterial Pinghan and Longhai Railways, which would have directly endangered the major cities of Wuhan and Xian. To stop further Japanese advances, Nationalist troops intentionally broke the levees of the Yellow River near Huayuankou to “use water as a substitute for soldiers.”13 Water flooded into Henan, Anhui, and Jiangsu. The floods covered and destroyed thousands of square kilometers of farmland and shifted the mouth of the Yellow River hundreds of miles to the south.14 Thousands of villages were inundated or destroyed and several million villagers were driven from their homes. In the following months, cases of infectious diseases were reported in the flooded areas. Japanese records show that cholera, paratyphoid, dysentery, and severe diarrhea were often reported to local authorities.15 Each side tried to blame the other for the outbreaks. And while the Chinese government did not undertake a major relief operation to aid the displaced, the Japanese took every chance to promote their “merciful action” in saving the population from the floods.16 However, there is no real evidence that either side engaged in much by way of emergency rescue activity in the immediate aftermath of the flooding unleashed on June 5. Any such operations would have had a very limited impact due to the huge areas affected.

9 The deliberate flooding of the Yellow River has been described as the “largest act of environmental warfare in history”17 causing the death of 470,000 to 500,000 people and the displacement of 5 to 6.1 million others.18 While the survivors blamed both the disaster on both the Japanese Imperialists and Chinese Nationalists, parts of the flooded region became a fertile recruiting ground for Chinese communists.19

10 The Nationalist government, although accused of inaction,20 did try to reduce the impact of the Huayuankou flooding, not through immediate action but through an urgent call for international assistance in this context of war. As early as 1933, in the defense of Gubeikou, Robert Lim had demonstrated the urgent need for military medicine in modern warfare in China, and also revealed the importance of the Red Cross Society of the Republic of China, the International Red Cross’ Chinese branch, for first aid in the field, as well as a channel for receiving international aid. By 1937, despite friction between the different organizations—the PUMC, the Nationalist government, and the International Committee of the Red Cross—the implementation of an emergency healthcare system and the constitution of a medical corps became the

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top priorities of both Red Cross Society of the Republic of China and the National Health Department in Nanjing.21 The American Bureau of Medical Aid for China (ABMAC) was essential to Robert Lim’s work. Set up mainly by Chinese Americans in 1937, ABMAC supplies were initially distributed to the Red Cross Society of the Republic of China and its Medical Relief Commission (later Corps), both headed by Robert Lim. At that time, China’s armed forces had only the most rudimentary military medical services22 and civilian medical services were insufficient too. In early July, immediately after the flooding of Huayuankou, ABMAC was able to make a grant of $ 1,000 to the Hankow Rest House and $ 1,000 to the University Hospital in Nanjing from the Bureau’s fund-raising efforts for Chinese refugees and flood victims.23 However, as Dr. Co Tui, ABMAC director, later stated “We had to hold on to the Nanking (Nanjing) funds, as the city fell into the hands of a puppet Japanese government at just about that time.”24 It seemed that foreign medical aid was suspended.

Reserving modern medical resources in wartime China

11 As the war progressed, Japanese forces progressively took control of Shanghai, the capital Nanjing and Wuhan, forcing the Chinese central government to relocate to , in , southwest China which was far from the reach of Western medicine. Records from the time show 8,900 registered physicians, 2,740 pharmacies and dispensaries, 3,700 midwives and 575 nurses in the entire country.25 In southwestern remote areas, most medical services were still provided by mostly unqualified practitioners and druggists practicing traditional Chinese medicine. In the countryside, where the majority of the population lived, practitioners were generally farmers who sold medicinal herbs as a sideline.26 The Nationalist government’s retreat to Chongqing coincidentally brought the resources of modern medicine to this part of China, paving the way for post-war reconstruction.

12 The core of the limited medical resource in southwest China was the well-trained medical practitioners and public health workers who had retreated with the government. These professions had been greatly supported by the Nationalist government’s medical modernization scheme in the 1930s. Dr. Robert Lim’s colleague, Liu Rui-heng (Dr. J. Heng Liu), the former chancellor of the PUMC and a Harvard medical school alumni had played a key role in promoting this modernization project by adopting American standards.27 One of Liu’s main tasks was to replace the dominant German configuration of Chinese military medicine to meet the criteria of American standards.28 Liu’s mission to reform medical training in the military was later taken over by Robert Lim and resulted in the creation of a reservoir of modern medical resources within the military as well as the maintenance of links with American supporters.29 This became very important when the Nationalist government retreated to Chongqing and relied heavily on military personnel to keep modern epidemic control systems running. Based on the experience he had gained in Northern China and through international connections with ABMAC as well as other American aid organizations, in 1938, Dr. Robert Lim set up the Emergency Medical Service Training School in Guizhou. This was the first such establishment for training doctors, nurses and medical orderlies for the army and civil relief services. This school later expanded to several campuses and units until 1942. The school’s mission was to respond to the medical demands of the battlefield and to provide the means for post-war

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reconstruction.30 During the war, over 13,000 medical personnel of various categories were trained there.31 The Emergency Medical Service Training School was sponsored by the Nationalist government and ABMAC and staffed by some of Robert Lim’s former PUMC students and colleagues. They worked alongside the renamed Medical Relief Corps in spreading modern medical knowledge to army medical personnel and local communities. During the whole period of resistance to the Japanese invasion, the Emergency Medical Service Training School worked with ABMAC and played a key role in receiving American aid and merging the German system into American standards. With the help of American resources received via ABMAC during this war period, Robert Lim continued the work in Guizhou that had been started in Nanjing by his former PUMC colleague Liu Rui-heng.

13 At first sight, the Emergency Medical Service Training School was set up for military purpose; however, the reasons behind its establishment in southwest China were more ambitious. A review document from the Rockefeller Foundation revealed that on the recommendation of ABMAC, the main target was to relocate the Army Medical Service Training Unit to the Emergency Medical Service Training School in Sichuan under Lim’s commend. A CMB report from the time states: “I am certain that if there is continuity after the war in national health training, it will prove to be of a much more significant nature than pre-war training, due to the methods of training introduced in Changsha by Robert Lim.”32 With the effects of the war, the project of establishing public health centers in the 1930s by Liu Rui-heng and its mission of controlling epidemics was so extended that the single Central Training Station in Chongqing was obviously insufficient. Boosted by graduates from the Emergency Medical Service Training School and army medical corpsmen, provincial and county centers were rapidly established, beginning with Guizhou and remote counties of Sichuan.33 For example, in 1941 the National Health Administration reported that 76 of 84 counties in Guizhou had established such health centers while only 11 counties had such services before 1935.34 In 1944, the Provincial government of Sichuan reported that 116 of 140 counties in Sichuan had “some form of health center.”35

14 The effort to continue the medical training program and local health reforms in southwest China was not intended to immediately reduce the health crisis in China during the war, but to maintain the capability to implement post-war reconstruction. From 1941, students from Emergency Medical Service Training School, for example, were asked to join the Army Sanitary Corps and the Red Cross Medical Relief Corps on the battle front and in unoccupied areas. While the school and its branches were designed to act as medical centers or battlefield stations in times of war, they would easily be converted to civilian healthcare in peacetime.36 By the end of 1943, near 66% of the graduates of Emergency Medical Service Training School were removed from combat zones and relocated to various positions in civilian services.37 The Emergency Medical Service Training School and the Central School of Army Surgery were both located in Guizhou and provided medical care for the military and civilian population.38 Between 1941 and 1945, the Emergency Medical Service Training School therefore had a double role. It trained servicemen for medical duties and at the same time trained local people to respond to both military and civilian medical needs.39 Dr. Robert Lim planned that these local trainees would form the foundation for healthcare after the end of the war.

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15 The results of Dr. Lim’s plan seemed positive. Major Mendelson of the US Army visited the Emergency Medical Service Training School in 1942, and declared that the technical short-term emergency training was managed effectively, showing good results in the prevention and mass-treatment of disease.40 The progress of sanitary training was made in two ways: the enrolment of local helpers for public health services, and establishment of several nursing schools for young women. To improve the transportation of medical services, a field ambulance battalion was organized and staffed with Army medical officers and Red Cross personnel to teach local helpers how to coordinate supplies and personnel requirements. The purpose was to increase the numbers of trained medical personnel who could support the military in times of war and work in their local communities during peacetime.41 The picture showing the group photo of graduating stretcher-bearers attests to this effort (photo 1). Moreover, American officers were to be attached to these units, if available. Some of the best of Chinese officers and staff were sent to America for advanced training with the US Army. After returning home, they were charged with training as many instructors as possible, military and civilian, who would be sent to the front and to unoccupied areas. 42 This strategy was clearly not only for the specific medical demands of wartime, but was also for the peacetime that would eventually follow.

16 In the 19th century, when the Chinese encountered Western medicine, their first sight was commonly a nurse caring for a patient. Although nurse training has a long history in China, dating from the arrival of missionaries and missionary medicine, according to the CMB only a few schools offered advanced nursing programs which could meet American standards. From 1920 onwards the PUMC served as the first graduate school for the training of teachers of nursing and hospital administrators and offered a combined course in which graduates of a two-year pre-nursing course could continue to a three-year course at the PUMC leading to a Diploma in nursing and a Bachelor degree.43 In 1930, the headquarters of the Nurses Association of the Republic of China (NARC), supported by the CMB, moved to Nanjing. In addition to Western nurses, the majority of NARC members were PUMC alumni, which reveals its close connection to American medicine.44

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Photo 1. Bearer training and local stretcher-bearer

Courtesy by John Watt of ABMAC.

17 During the Sino-Japanese war, many young Chinese women who aspired to serve their country were attracted by the nurse training programs.45 However, the Central School of Army Surgery was an all-male unit even in wartime. With continuing help and donations from the ABMAC, the Emergency Medical Service Training School at Tuyunguan had gained experience of treating open wounds with sulfanilamide powder. 46 However, due to the limited number of military surgeons and civilian physicians in the region, most of the treatment was done by nurses or nursing orderlies trained at the Emergency Medical Service Training School. The nursing department of that school was headed by a PUMC graduate, Miss Zhou Mei-yu. Zhou divided the department into two training sections. One was a regular school for registered military and civilian nurses. The other was an intensive program in basic nursing skills, mostly addressed to local women who would later serve as formal nurses’subordinates.47 This form of nurse training was very beneficial to local communities and had a similar impact to the training of local stretcher-bearers.48

18 The selection of local candidates for Emergency Medical Service Training School nursing programs reveals China’s socio-economic conditions. Graduation from a junior middle school was required for admission, while formal schools of medicine and nursing demanded senior high school graduation. The reason of such criteria was, as a recruitment poster reveals: “graduates (of junior middle school) those who already have sufficient cultural and political background will benefit their hometown at the same time as promoting national policy… At this age they are usually more receptive, idealistic, and unafraid of the difficulties and hardships in training and the mission of bringing new knowledge back to home… The graduates’families in their hometown are usually better off financially, which will also secure their social status at the same time as promoting modern medicine in conservative rural areas….”49 Although American observers in 1943 had criticized the Emergency Medical Service Training School’s curriculum as “a limit to which unqualified personnel can be technicalized and

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promoted…”50, the effort to maintain modern healthcare systems in wartime China for post-war reconstruction was later carried on by the creation of the National Defense Medical Center in 1947. The NDMC moved with the Nationalist government to Taiwan in 1949, bringing with it some of its war-time experience.

Post-World War II legacy one: fighting epidemics as if fighting the enemy

19 In the optimistic atmosphere created by the victory against Japan in 1945, the Nationalist government announced a series of public health projects on its return to Nanjing.51 Although some of these projects were unrealistic in the devastated post-war conditions, several institutes were established with American support.52 For example, The Malaria Research Institute, founded in 1936 with support from the Rockefeller Foundation and the CMB, moved from Yunnan to Nanjing with the Rockefeller Foundation’s support in 1947. An experimental DDT spraying project was also set up in the same year with many tons of free chemicals from the US army. In 1947, Jiangning, a village outside the city of Nanjing, was jointly selected by the Rockefeller Foundation and the government to set up an experimental DDT spraying station—the first such demonstration station on Chinese territory—under the direction of malariologist Zhou Qinxian and American scientist Robert Briggs Watson. At this time, levels of malaria on the newly-liberated island of Taiwan were much lower than on mainland China and the island did not receive supplies of DDT.53 Despite medicine and sanitation being modernized during the Japanese colonial period (1895-1945),54 in early post-World War II years Taiwan was in bad shape and suffered from many epidemics.55 However, mainland China received the majority of American donations of medical resources until late 1947, when the provincial government in Taipei started to receive significant aid from the US.56

20 Controlling epidemics was not the only motive for the Nationalist government to resume the 1930s project and build on its wartime experience. During the first-half of the 1950s, the Nationalist government in Taiwan was eager to gain the support of the US to block invasion from mainland China. Maintaining philanthropic work such as epidemic control and public health improvement in Taiwan could be a strategy to continue the cooperation between Nationalist Taiwan and the US in the post-World War II era.57 After the end of the war, James A. Crabtree, Deputy Surgeon General of the US Public Health Service from 1946 to 1948 promoted the idea of building a new organization for international public health,58 a mission that had been carried out by the League of Nations before the war. World War II had severely curtailed the international cooperation-based disease control efforts carried out by the Health Section of the League of Nations in Geneva, a European city trapped in the debris of war damage. A proposal by Brazil and China to establish an international health organization in the 1945 San Francisco Conference was soon recognized by the US Public Health Service.59 Civilian organizations including Johns Hopkins University, the Rockefeller Foundation, and the American Medicine Association recommended specifically that the United Stated government include non-governmental charity resources in the early formation of a new international organization that would be closely linked to the United Nations.60 With abundant American resources from both governmental and private organizations, the World Health Organization represented a

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multi-lateral approach to international public health, also mobilizing the cooperation of many nations in pursuing common goals.61 The involvement of American civilian doctors and military surgeons for public health reconstruction in East Asia was benevolent but also political and strategic. Public health and medical reform in China could be seen as part of the broader American model of the professionalization of medicine in an East Asian ally after World War II.

21 When the first WHA (World Health Assembly) conference passed the charter to establish the WHO in 1948, the Nationalist government in China had already lost diplomatic support from the US government along with all forms of aid. After the failure of negotiations by General George C. Marshall in China, President Truman announced in The China White Paper in August 1949 the withdrawal of all support from China and blamed the decision on corruption in the Nationalist government. The damage to the Nationalist government was tremendous; it notably caused its retreat to Taiwan.62 Following this change of US diplomatic policy toward China, the China Medical Board also stopped its aid to China and prepared to withdraw its staff from Taiwan.63 Even Robert Lim was losing his support from American colleagues in US, as one member of CMB put it: “nor am I sure that he is still serving in that capacity (of seeking donations in/from the US).”64 Moving to Taiwan and making compromises to accept doctors who had been trained in Japanese colonial medicine was the only solution for the Nationalist government in 1949.

22 At the end of World War II, Taiwan was returned to China and became re-integrated into China’s administrative structure. As far as health matters were concerned, the island not only underwent changes in the organization of its health agencies, but was also very affected by the spread of diseases from the mainland.65 In 1945, the Taiwanese provincial government reorganized the health model inherited from the Japanese by removing Public Health from the Police Department and placing it in a new Bureau of Sanitation (Weishengju).66 The change did not, however, create a strong and efficient agency. A scholar underlined how public health in early postwar Taiwan was merely a system that “put out fires,” and not a reliable system to handle the needs of public health.67 In 1946, a Rockefeller Foundation evaluation of sanitary conditions in Taiwan revealed the “modern” and “medieval” aspects of Japanese colonial sanitation. The use of night soil for fertilizer, sleeping and living on wooden floors in small damp houses, and many other customs were potential public health risks. Before World War II, the Sanitary Police were in charge of environmental sanitation but its members lacked proper training in public health and its budget was limited.68 Undoubtedly, post-war Taiwan urgently needed new health resources and administrative skills to fill the vacuum caused by the defeat of the Japanese in August 1945. Changes of government, economic depression, movements of people, shortages of medication, and the neglect of the public health infrastructure all contributed to the resurgence of infectious diseases in Taiwan between 1946 and 1947. Cases of cholera, smallpox, and plague were reported, and it is estimated that more than one million people were infected with malaria during these years.

23 In order to stop the further spread of epidemics from mainland China, new regulations for port quarantine, based on the most updated standards, became effective in December 1946. Taiwanese personnel manned the ports of entry under the guidance of Chinese officials, who were themselves trained in laboratory techniques under American supervision.69 Owing to the poor health conditions in post-war Taiwan, the

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Chinese Nationalist government put in place stringent immunization requirements, and in 1947, revised the regulations to bring them more in line with standard international quarantine practices.70 Under the supervision of the Plague Prevention Division of Southeast China, a section of the National Health Department of the Nationalist government that channeled foreign medical aid, quarantine controls proved successful.

24 The diversion of labor and materials during the Sino-Japanese War had a dramatic impact on epidemic control, even by the relatively low 1945 standards. Smallpox vaccination programs were either completely discontinued or were not enforced from 1945 to 1946. Environmental sanitation was virtually nonexistent, while public water supply and waste collection facilities had been severely damaged in areas that had been bombed or suffered from lack of funds.71 Those areas that escaped the devastation of war had deteriorated badly through neglect, as well as a shortage of materials and supplies. The withdrawal of American organizations further suffocated the re- construction of the public health infrastructure in Taiwan. The ABMAC along with other American organizations had cooperated with the Nationalist government to improve public during and after the Sino-Japanese war.72 But unlike the CMB and other American counterparts, the ABMAC continued to cooperate with the Nationalist government after its retreat to Taiwan.73 Aware of the decision made by the US State Department and CMB, the ABMAC chose to support the Nationalist government in Taiwan.74

25 ABMAC saw communism as a threat to religious freedom, and especially to Christianity. To keep the donation to “Free China (Taiwan),” the Executive Committee of ABMAC repeatedly asserted “No gift to the ABMAC ever goes to Communist-held areas […] the donation will only be sent to Free China.”75 Between 1949 and the outbreak of the Korean War in 1952, the ABMAC was the sole channel of American influence in public health in Taiwan. Working with the National Defense Medical Center in Taiwan, Liu Rui-heng replaced Robert Lim as ABMAC representative.76 To secure the limited medical aid from the ABMAC, Liu encouraged the NDMC faculty to resume some programs that America had proposed earlier in pre-civil war mainland China. Starting in 1951, the former malariologist at the Nanjing station Zhou Qinxian and Zhang Teling, an NDMC parasitologist initiated a DDT spraying pioneer project in South Taiwan.77 The project was in fact the miniature version of that carried out in 1947 on the mainland with ABMAC support. The pioneer project was later expanded to an island-wide program in 195278 which was soon recognized by the WHO as a part of the global anti- malaria program.

26 American medical aid to China and Taiwan helped break down the fatalistic view of diseases and natural disasters as parts of the regular natural cycle: by blaming plagues and the flooding on the Japanese invasion, they drew a link between fighting to victory on the battlefield and fighting the ravages of epidemics and natural disasters. A cartoon in 1947 of the first annual report of the NDMC dramatically reflected such a link (Photo 2). Treating diseases and public health crises as a real enemy in a combat situation had strong resonance in post-war Taiwan and left a deep impact on the anti- malaria program in the 1950s and 60s.79

27 The outbreak of the Korean War in 1952, with the USSR and Communist China supporting North Korea and the USA supporting the South, intensified the Cold War and brought American medical aid back to Taiwan. American sources of medical aid in

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the 1950s and 1960s included public agencies such as the Economic Cooperation Administration, private foundations such as the Rockefeller Foundation, the Population Council, and the ABMAC as well as the General Headquarters (GHQ) in Tokyo, and universities such as Princeton and the University of Michigan. Foreign assistance brought new forms of medical treatment and also introduced very different strategies in the identification of disease and public health problems.80

Photo 2. The double-mission to fight enemy and disease.

Source: The Second Annual Report of NDMC (1948).

Post-World War II legacy two: the American panacea and Taiwanese takers

28 The malaria eradication campaign is a very good illustration of the importance of the American model of public health and medicine in health development in postwar Taiwan. The campaign was also part of a global effort to combat this deadly disease by DDT indoor residual spraying (IRS). While Randall Packard81 and Yip Ka-che 82 have demonstrated that the result of the campaign depended to a significant extent on the social and political conditions of each country, and on the importance to have qualified personnel, in East Asia, Taiwan was a successful case in this global DDT campaign of malaria eradication.

29 The DDT program launched in 1951 directly linked anti-malarial activities in Taiwan to a global effort in partnership with the WHO. The first objective of the 1951 agreement between the Nationalist government in Taiwan and the WHO was “the control of malaria and eventually the eradication of this disease in the whole island of Taiwan, with modern methods at the lowest feasible cost.”83 The project aimed to control

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malaria and other insect-borne diseases, and improve the health of the population, agricultural production as well as the general economy. The eradication program was preceded for two years by scientific study into the effectiveness of IRS DDT spraying when applied to walls made of different materials, field research into mosquito habitats, and cost-effectiveness studies of the various eradication procedures.84 Generous financial and technical support from the US helped ensure the success of the program, which benefited almost every aspect of life in Taiwan.

30 The 1950s’DDT program in Taiwan not only laid the foundation for future malaria control by combining knowledge and experience from Taiwan’s colonial past and mainland China, but also significantly boosted Taiwanese confidence in American public health practices. Along with the rising confidence in American medicine, more reforms were on the way. Two American experts, Van Hoge and Ross Porter, produced an evaluation of public hospitals in Taiwan in 1952 that recommended a radical make- over of the whole system.85 To further promote the American model of public health, the Nationalist government launched a five-year Integrated Health Project in 1959 to train Taiwanese medical professionals in the “integration of curative and preventive medical service”86—a radical change from colonial medical training to a much broader public health approach. In addition, American experts pointed to the general weakness of environmental sanitation in post-war Taiwan as a result of the Japanese colonial policy of focusing mainly on urban sanitation. Working with the Sino-American Joint Commission on Rural Reconstruction (JCRR),87 American aid agencies subsidized the establishment of the Provincial Institute of Environmental Sanitation which went on to create many rural health stations in 1955.88 The “rural health station,” an organization that had been launched in the 1910s by PUMC, was maintained during the 1940s in wartime China, and was then extended island-wide in Taiwan. In addition to setting up the rural health stations, the Institute also trained nurses and technicians who would work in them. The training unit was under American supervision.89 It is worth noting that many rural public health projects in Taiwan originated from the JCRR’s original plans and experience in mainland China.

31 The retreat from the mainland brought to Taiwan transmissible diseases as well as new ideas and technologies to control them, such as the JCRR rural health station plan and the DDT spraying program and other ideas and technologies. With a long history of embracing American medical education and practices, medical professionals who had retreated from the mainland with the Nationalist government, especially military surgeons, attempted to reshape the Japanese medical model in Taiwan, stressing the nationalistic aspect of the change. Ironically, the pressure of postwar epidemics and cold-war politics brought a focus to the efforts to reshape public health practices in Taiwan which might otherwise have resulted merely in conflicts among various medical factions.

32 In 1949, with help from the CMB and the ABMAC, two-thirds of the NDMC staff moved to Taiwan. In Taiwan, General Zhou Mei-yu received American support for military nursing education at the NDMC.90 Yu Daozhen, a protégée of General Zhou, was invited to set up a Department of Nursing at the National Taiwan University (NTU) in 1956.91 Following the guidance of her mentor General Zhou and American supporters, Yu transformed the military nursing training program into a public health nursing program.92 The ABMAC, the RF, and the CMB provided additional support to help establish nursing schools at various levels, and in implementing the rural health

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station project.93 In addition, Yu’s students also claimed that “the reform of nursing education at the NTU led to the transformation from the German-Japanese system to the British-American system.”94

33 From 1952, the authorities in Taiwan began formulating long-term plans for improvements based on previous Rockefeller Foundation proposals, but any implementation of the plans would depend, to a large extent, on the cooperation of local governments and medical professionals in Taiwan. Following the outbreak of the Korean War, the US Foreign Operations Administration (FOA) sent Emile E. Palmquist and Kaarlo W. Nasi to review Taiwan’s medical and public health conditions.95 Their report later served as the basis for the US AID Health Program in Taiwan aimed at maintaining economic stability and military power in Taiwan. The report stressed that the target institute to which an ambitious program of rehabilitation and technical support would be affiliated should be carefully selected.96 Moreover, as Dr. Edger Hull, Medical Consultant to the Mutual Security Agency mission to China (MSA) expressed his strong concerns about the quality of the NDMC public health program,97 the dean of pathology at NTU also started the “Americanization” of its public health program at NTU with NDMC’s close cooperation.98

34 In 1951, two American public health experts from the ABMAC, Dr. Magnus I. Gregersen and Dr. George H. Humphreys of Columbia University, evaluated the medical school at the NTU. Although their proposal for medical school reform was too expensive to be implemented, their visit brought the school to the Rockefeller Foundation’s attention and ABMAC later provided some support to the school.99 In late 1951, the former dean of the Public Health Department of PUMC, Dr. John B. Grant, was invited by Liu Rui- heng to help the conversion of the Tropical Institute at NTU into a Department of Public Health which was later established with the Rockefeller Foundation’s full support. The successful creation of nursing and public health departments laid the foundation for long-term cooperation between the NTU and various American aid organizations.100 In 1955, the US Naval Medical Research Unit No. 2 (NAMRU-2) decided to relocate to the affiliated hospital of NTU in Taipei. Affiliation with an advanced research institute and a significant symbol of American medicine in the Far East, vastly enhanced the NTU’s prestige in the eastern Pacific Rim region.101 With this decision, American medicine was overwhelmingly accepted by Taiwanese and the strategic relationship between the two countries could be further secured as the US AID Health Program had expected.

35 During the 1950s, although the proportion of direct public health and medical aid to Taiwan was relatively insignificant, accounting for about 6% of the total amount of American aid between 1951 and 1965,102 the major portion of US support for Taiwan’s public health and medical improvements was more indirect, being found in other aid projects. For example, around 10% to 15% of the American aid was earmarked for work in rural reconstruction which would lead to public health benefits. Meanwhile, the Council for United States Aid (CUSA) and the Taiwanese Provincial Health Department worked together in coordinating foreign medical aid from the United Nation Children’s Fund (UNICEF), the World Health Organization (WHO), and ABMAC.103 Soon after the successful conclusion of the DDT anti-malaria program, people in post-war Taiwan came to believe that foreign aid in medicine would definitely improve public health and medical conditions in the island.

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Concluding remarks

36 This article shows that the role that American philanthropic organizations such as the Rockefeller Foundation, the China Medical Board, and the American Bureau for Medical Aid to China fulfilled in the public health modernization of the country was highly limited in the case of Republican China. If their work in Mainland China during the Sino-Japanese war was an anomaly, it nevertheless influenced philanthropic interventions in other parts of post-World War II East Asia,104 and particularly in Taiwan during the Cold War. On the surface, US funded public health reform in China is in line with the global promotion of American epidemic control principles by these philanthropic foundations. The control of epidemics in Taiwan was a philanthropic mercy as well as a military strategy.105 How did epidemic control become a strategic tool in the Cold War? During his trip to Asia in 1953, political observer James Reston reported: America’s contribution to the safety and sanity of Asia, however, goes well beyond the products of her factories… In Korea, Japan and Formosa (Taiwan), dependence on America is so great as to be almost pathetic. I had long talks with Syngman Rhee, Premier Yoshida of Japan and Chiang Kai-shek. Each in his own way had criticisms to make of American policy and all were asking more.106

37 Reston’s description may have merely revealed the general feeling about American medical aid to East Asia where Free China or Taiwan is located.

38 In these conditions, American medical models and professional practices eventually guided public health reform in Taiwan between 1952 and the 1960s, creating new methods for epidemic control and new professional standards for the postwar generation. In the 1960s, as the crude death rate of Taiwanese males dropped to less than one per cent,107 the phenomenon implied a dramatic transformation of leading causes of death. The success of the epidemic control program must have played a significant part in such a transformation (Chart 2).

Chart 2. Leading causes of death in Taiwan in 1942 and 1952

1942 1952

Diseases Percentage Diseases Percentage

Malaria 10.7 Gastris and enteritis 14.2

Maternal causes 9.2 Pneumonia 13.8

Gastris and entritis 8.5 Tuberculosis 9.6

Tuberculosis 7.1 Heart disease 5.2

Stomach and peptic ulcer 6.8 Stroke 5.1

Pneumonia 4.4 Perinatal mortality 4.6

Bronchitis 4.1 Nephritis and nephritis 3.8

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Meningitis 1.9 Cancer 3.2

Stroke 1.4 Bronchitis 3.0

Heart disease 1.3 Malaria 2.9

Sources: Taiwan Provincial Government (ed.) (1947). Taiwansheng wushiyi nien lai tongji tiyao (The 51- Year Statistical Summary of Taiwan Province). Nantou, Taiwan Provincial Government, digital data on http://twstudy.iis.sinica.edu.tw/twstatistic50/and National Health Administration, online databank on website: http://www.doh.gov.tw/CHT2006/DM/DM2_2.aspx? now_fod_list_no=9510&class_no=440&level_no=1 (2013/5/5 accessed).

39 The transition from Japanese colonial medicine to a system based on American standards brought medical professionalism in Taiwan to contemporary levels. Many scholars have therefore seen that the 1950s was a crucial period in the first stage of demographic transition in Taiwan which provided human resources to the fast economic growth experienced during the 1970s-1980s.108 Chart 2 again confirms this health transition.109 Generally speaking, Cold War politics played a key role in bringing American medicine to Taiwan as described above. However, without the earlier cooperation in mainland China, the Americanization of public health infrastructure in Taiwan after the retreat of Nationalist government in 1949 might not have been smooth and rapid as it was.

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YIP Ka-Che (ed.) (2009). Disease, Colonialism, and the State: Malaria in Modern East Asian History. Hong Kong, Hong Kong University Press.

ZHANG Jian-qiu 張建俅 (2001). “Kangzhan shiqi zhandi jiuhu tixi de jiangou ji qi yunzuo: yi Zhongguo hongshizihui jiuhu zongdui wei zhongxin de tantao 抗戰時期戰地救護體系的建構及 其運作—以中國紅十字會救護總隊為中心的探討 (The Field First Aid System During the Sino- Japanese War —The Medical Relief Corps of the China Red Cross).” Bulletin of the Institute of Modern History, Academia Sinica, no. 36: 117-165.

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ZHANG Pengyuan 張朋園 and LUO Jiurong 羅久蓉 (1993). Zhou Meiyu xiansheng fangwen jilu 周美玉 先生訪問紀錄 (Interview with General Zhou Meiyu). Taipei, Institute of Modern History, Academia Sinica.

ZHANG Zhi-jie 張之傑 (July, 2000). “Zhongguo sheng li xue zhi fu: Lin Ke-sheng 中國生理學之父： 林可勝” (The father of physiology in China: Lin Ke-sheng). Science Monthly 科學月刊, no. 367: 616-622.

ZHAO Jichang 趙既昌 (1985). Meiyun de yunyong 美援的運用 (The application of US aids). Taipei, Lienjing.

ZHONGGUO GUOMINDANG ZHONGYANG WEIYUANHUI (ed.) (1981) 中國國民黨中央委員會黨史會編. Zhonghua minguo zhongyao shiliao chubian: dui Ri kangzhan shiqi 中華民國重要史料初編—對日抗戰 時期 (The primary archives of Republic of China: the period of anti-Japanese war). Taipei, Zhongguo Guomindang dangshi weiyuanhui.

ZHONGHUA MINGUO WAIJIAO WENTI YANJIUHUI (ed.) 中華民國外交問題研究會編 (1965). “Rijun qinfan Shanghai yu jinggong Huabei 日軍侵犯上海與進攻華北 (Japanese military invasion to Shanghai and Northern China).” Zhong-Ri waijiao shilaio congbain, vol. 3 中日外交史料叢編（三） (The collection of Sino-Japanese diplomatic archives, vol. 3). Taipei, Zhonghua min guo waijiao wenti yanjiuhui.

ZHUANG Rong-hui 莊榮輝 (2000). “‘Shi qu Zhongguo?’ Jianjie Meiguo waijiao shijia you guan Dulumen zhengfu dui Zhongguo neizhan zhengce zhi lundian”

「失去中國﹖」簡介美國外交史家有關杜魯門政府對中國內戰政策之論點 (“Loosing China? Short Presentation of Arguments by American Historians of Foreign Relations on Truman Government’s Policies about Chinese Civil War”) Jindai Zhongguo 近代中國, no. 138: 133-156.

ZHUANG Yong-ming 莊永明 (1998). Taiwan yiliao shi: yi taida yiyuan wei zhu zhou 台灣醫療史──以台 大醫院為主軸 (Taiwan’s history of medicine: focuing on NTU hospital). Taipei, Yuan liu chubanshe.

NOTES

2. Liu 2011. 3. A great deal of financial support and ideas to reform public health infrastructure in China were provided by the Rockefeller Foundation and its affiliate the China Medical Board. The Rockefeller Archive Center is a treasure for historians who are interested in finding primary documents on medical reform in Republican China. The Center also holds other resources on medical aid to China from the US thanks to the Foundation’s central position in medical reform in China since the first decade of the 20th century. 4. Yip 1995. 5. Yip 1982: 1197-1205. 6. For a review of their work in medical modernization in China, cf. Bullock 1980; Ferguson 1970. 7. Lindsay 1945: 172-176; Hsu and Chang 1971: 159-161. 8. Zhonghua minguo waijiao wenti yanjiuhui 1965; Zhongguo Guomindang zhongyang weiyuanhui 1981; Liaoning renmin chubanshe 1991. 9. Shi 2005: 517-573. 10. “Dr. Robert Lim Outlines Medical Relief Work,” no. 66, June 21, 1941, Daily Bulletin, China Information Committee, folder “National Red Cross Society of China, Robert K.S. Lim,” box 22, series II: Permanent file, ABMAC, RBML, Columbia University.

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11. Rockefeller Archive Center (abb. RAC), RF archive, RG 2-1954, Series 601, Box 45, Folder 305, “Robert K.S. Lim.” 12. On the medical schools in the first decades of the 20th century, cf. Lucas 1982; Anonymous 1933; and Yin 2008. 13. Lary 2004: 143. 14. Lary 2001: 191-207. 15. Xin min hui nianbao 1938: 322-327. 16. Zhina shibian huabao, no. 33 (Meiri xinwen, July 11, 1938). 17. Taylor 2009: 154-155. 18. Perry 1980: 15. 19. Lary 2001: 204. 20. Lary 2001: 204. 21. Zhang 2001. 22. Watt 1992: 2. 23. RAC, RF archive, RG 2-1954, Series 200, Box 10, Folder 70 “Medicine on a Mission”: 4, 5. 24. RAC, RF archive, RG 2-1954, Series 200, Box 10, Folder 70 “Medicine on a Mission”: 4, 11. 25. Watt 1992: 3. 26. The condition of medical services was commonly criticized by American donors. The Rockefeller Foundation and the CMB repeatedly played on the poor medical infrastructure in order to promote themselves as the heroic saviors of China. RAC, RF archive, RG 2-1954, Series 200, Box 10, Folder 70 “Medicine on a Mission”: 16-18. 27. For Liu Rui-heng’s career, please refer to Liu 1989. 28. Wu 1995: 12-14. 29. Wu 1995: 13-29. 30. Liu 1993: 147. 31. RAC, RF archive, RG 2-1954, Series 601, Box 45, Folder 305, “Robert K.S. Lim.” 32. RAC, RF archive, RG 1.1, Series 601, Box 5-6, “Annual report, 1938.” 33. League of Nations Health Organization 1938: 1-3. See also Bullock 1980: 193. 34. “Public Health and Medicine,” China Handbook, 1937-1943 (New York, Macmillian, 1943): 667, 674. 35. Bullock 1980: 198-99. 36. Emergency Medical Service Training School (ed.), Announcement (1941): 1. 37. Emergency Medical Service Training School (ed.), Second Report (1942-1943): 4. 38. Emergency Medical Service Training School (ed.), Training Program: Stage medical Education (1941): 6-8. 39. Emergency Medical Service Training School (ed.), Training Program: Stage medical Education (1942): 12. 40. RAC, CMB Inc. archive, Series CMB, Box 122, Folder 886, “G. Correspondence.” 41. Emergency Medical Service Training School (ed.), Second Report (1942-1943): 16-17. 42. Emergency Medical Service Training School (ed.), Second Report (1942-1943): 17 43. Liu 1991: 315-324. 44. Liu 1991: 322-323. 45. Pan 1997: 129. 46. Emergency Medical Service Training School (ed.), Second Report (1942-1943): 51. 47. Emergency Medical Service Training School (ed.), Report (1943): 22. 48. The stretcher-bearer was mainly civilian but could be recruited to work as supplement combat medics. (Ibid.) 49. Emergency Medical Service Training School (ed.), Report-supplement (1942): 40-41. 50. RAC, CMB Inc. archive, RG 1-1945, Series CMB, Box 162, Folder 812, “G. Correspondence.” 51. Chen 1981: 21.

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52. Chen 1982: 14. 53. RAC, Robert Briggs Watson, “Annual Report of Activities, 1946,” RG 5, IHB/D, Series 3, Box 217, Folder 600. RAC, J.H. Paul, “A report on the year’s activities for year 1946,” RG 5, IHB/D, Series 3, Box 217, Folder 600. 54. Liu 2009. 55. Chen 2000: 35-36; Zhuang 1998: 364-365. 56. RAC, “Annual Report 1949,” p. 3, RG 5, IHB/D, Series 3, Box 217, Folder 600. 57. Ambivalence about how the security situation in East Asia was assessed by the US can be found among seasoned experts. For example, Scalapino 1991/1992: 26, 32, 36. 58. Williams 1951: 487. 59. Williams 1947: 68. 60. World Health Organization (ed.) 1958: 38-40. 61. Williams 1951: 821-824. 62. Zhuang 2000: 143-144. Although the letter from the Rockefeller Foundation to the CMB did not point out the causality between the China White Paper and the withdrawal of personnel, it did quote from the China White Paper to illustrate the Sino-American relations. For cases, please check RAC, “Letter from Chester I. Barnard to John D. Rockefeller 12, Sept., 1950,” Collection: RF, RG: 2-1950, Series 200: US, Box 478, Folder 3207. 63. RAC, “Letter from Dr. Balfour to Dr. Strode, 25, Feb., 1949,” Collection: RF, RG: 1, Series 601, Box 44, Folder 361. 64. RAC, “Letter to Dr. Hugh Smith, May, 22, 1950,” Collection: RF, RG: 2-1950, Series 601, 605, Box 501, Folder 3349-3350. 65. For a case study of epidemics in early post-World War II Taiwan, see Chen 2000. 66. Su 2004: 185. 67. Chen 2000: 101-105. 68. RAC, CMB, RG 5, IHB/D, Series 3, Box 217, Folder 600, “Annual Report 1949”: 3-5. 69. “Gechu guanyu meiyun yiyao buzhu defang de yuebaobiao he laiwang gongwen” [Various monthly reports and documents on American medical aid], archives of Weishengbu (National Health Department), Box 372, no. 613 (1947), The Second Historical Archives of China (Nanjing). 70. RAC, CMB, RG 5, IHB/D, Series 3, Box 217, Folder 600, “Annual Report 1947.” 71. RAC, CMB, RG 5, IHB/D, Series 3, Box 217, Folder 600, “Annual Report 1949.” 72. Watt 1992. 73. RAC, RF, RG: 2-1949, Series 200US, Box 441, Folder 2969, “Medicine on a Mission: A History of American Bureau for Medical Aid to China, Inc. 1937-1954”: 28 (section III). 74. RAC, RF, RG: 2-1949, Series 200US, Box 441, Folder 2969, “ABMAC, Board Director’s Meeting Agenda.” 75. RAC, RF, RG: 2-1951, Series 200, Box 516, Folder 3449, “Note of ABMAC, 21, May, 1951.” 76. Zhang 2000: 616-622. 77. Wu 1995: 37 and 41. 78. Xingzhengyuan weishengshu 2003: 23-25. 79. Lin and Liu 2010: 183-208. 80. Yang 2008: 91-139. 81. Packard 2007. 82. Yip 2009. 83. “Annexes to the Plan of Operations for Malaria Eradication in China (Taiwan),” Document 2025, 69, Taiwan Provincial Malaria Research Institute (TAMRI). 84. Watson and Liang 1950: 471-486; Watson, Paul and Liang 1950: 25-43. 85. “Counterpart Budget – PH CY-1953,” March 30, 1953; “CY-53 Counterpart Allocation,” June 9, 1953, CIECD36-11-003-001, Institute of Modern History of Academia Sinica (hereafter IMHAS).

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86. “Application for Local Currency AID Funds-Project #84-55-514,” Dec. 29, 1959, CIECD36-11-003-046, IMHAS. 87. The Sino-American Joint Commission on Rural Reconstruction (JCRR) was established in 1948 in mainland China, then moved to Taiwan, where its work has been widely credited with laying the agricultural basis in the 1950s and 1960s for Taiwan’s economic, social, and technical development. For its brief history, see Yager 1988. 88. “Taiwan shengzhengfu weishengchu zhi meiyunhui han” [Letter from Taiwanese Provincial Health Department to CUSA], April 5, 1957 and “Project Agreement Between ICA and CUSA,” March 6, 1958, CIECD36-11-003-067, IMHAS. 89. “Project Proposal & Approval Summary (#84-52-291),” Jan. 8, 1957, CIECD36-11-003-067; “Report of Sanitarian Training Program,” Nov. 1, 1957; “Taiwansheng huanjing weisheng shiyenso zhi J. I. Connolly han” [Letter from Taiwan Provincial Institute of Environmental Sanitation to J. I. Connolly], June 6, 1958, CIECD36-11-003-067, IMHAS. 90. Memorandum: “Improvement of Nursing Practice Project-FY 1957 Program,” August 31, 1960; “FY 59 PPA-Aid to Medical and Paramedical Education (Improvement of Nursing Practices),” August 18, 1958, CIECD6-11-003-038, IMHAS. 91. Cai 2001: 261-262. 92. Chen 1996: 80. 93. Yang 2008: 111. 94. Liu 2006: 17. 95. “Zhi naizhengbu Taiwan shengzhengfu hangao” [Draft: letter from CUSA to the Ministry of Internal Affairs and Taiwan Provincial Government], Sept. 16, 1954, CIECD36-11-003-001, IMHAS. 96. Yang 2008: 108. 97. Lu Zhider zhi meiyuanhui han (Letter from Lu Zhider to CUSA), Aug. 7, 1958, CIECD36-11-003-104. 98. Yeh 1989: 56. 99. Watt 1995: 174-177. 100. Medical School of NTU (ed.), middle volume 1998: 16; Du 2008: 27, 29. 101. Xie 1995: 178-181. 102. Zhao 1985: 27-51. 103. Yang 2008: 95-96. 104. Similar pattern of medical intervention on epidemic control to Taiwan can also been found in Southeast Asia. See Anononymous 1954. 105. Siggers 1954. 106. Reston 1953. 107. National Health Administration, online databank on website: http://www.doh.gov.tw/ CHT2006/DM/DM2_2.aspx?now_fod_list_no=9510&class_no = 440&level_no = 1 (2013/5/5 accessed) 108. Such an argument is very popular in the fields of demographic studies and development economics. For a review of this argument and its impact to social transformation in Taiwan, cf. Freedman 1986. 109. A change in disease patterns in populations testifies to a health transition which is determined by four elements: Urbanization, demographic, epidemiologic, socio-economic and health care. For detail definitions, see Olshansky and Ault 1986.

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ABSTRACTS

Post-WWII Taiwan fast recovered its public health infrastructure from war damage due to aids from US and World Health Organization. Beside a long history between the Nationalist government and American aids since the 1930s, the reconstruction of public health in 1950s Taiwan shared experience of military medical works and epidemic prevention during the Sino- Japanese War. The article aims to survey the linkage between the reconstruction of public health in 1950s Taiwan and previous sanitary works of Nationalist government in wartime period, revealing possible influence of Cold War politics in East Asia.

Après la Seconde Guerre mondiale, Taiwan remet sur pied les infrastructures de santé publique fortement endommagées, grâce à l’aide des États-Unis et de l’Organisation mondiale de la santé. La reconstruction de la santé publique à Taiwan dans les années cinquante bénéficie de l’expérience acquise pendant la guerre sino-japonaise dans le domaine de la médecine militaire et de la prévention contre les épidémies. Cet article établit le lien entre la reconstruction de la santé publique dans le Taiwan des années cinquante et les travaux de santé publique menés antérieurement par le gouvernement nationaliste en période de guerre, en même temps qu’il révèle l’importance de l’influence politique de la guerre froide en Asie orientale.

二次世界大戰後的臺灣，由於美援與世界衛生組織(WHO)的協助，快速地從戰火破壞中重建公 共衛生秩序。然而，1950 年代的公共衛生秩序重建，除了國民政府自1930 年代以來即致力與 美援維持關係外，也隱約繼承著中日抗戰時期，國民政府戰地衛生勤務與防疫經驗延續的淵 源。本文以國府在戰爭時期—抗日戰爭與國共內戰，所累積之防疫工作與戰地衛生勤務經驗為 經緯，探討1930年代到50年代國府如何在美國醫藥援助下，恢復臺灣地區公共衛生秩序的過 程，並因此展開冷戰時期東亞國際防疫網與臺灣衛生工作之連結。全文討論始於1933年日軍入 侵華北，國府將防疫工作與衛生訓練寓於戰地醫護之中，而分析終於1950年代國府退守臺灣 後，如何以局部恢復之戰時衛生經驗，將臺灣重置於東亞之國際防疫網中，並據此再次取得 美國的援助及外交上的支持。

AUTHOR

MICHAEL SHIYUNG LIU

MICHAEL SHIYUNG LIU is research fellow at the Institute of Taiwan History (Academia Sinica, Taiwan). He earned his Ph.D. from the University of Pittsburgh in 2000. He works on the modern history of public health, Japanese colonial medicine, and historical demography. He is currently the Deputy-Director of the Institute of Taiwan History and Executive Secretary of Association of East Asian Environmental History. MICHAEL SHIYUNG LIU est chercheur à l’Institut d’Histoire de Taiwan (Academia Sinica, Taiwan). Il a soutenu sa thèse de doctorat à l’Université de Pittsburgh en 2000. Il travaille sur l’histoire de la santé publique, la médecine coloniale japonaise et la démographie historique. Il est actuellement vice-directeur de l’Institut d’histoire de Taiwan et secrétaire de direction de l’association d’Histoire Environnementale de l’Asie Orientale.

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Framing SARS and H5N1 as an Issue of National Security in Taiwan: Process, Motivations and Consequences La construction du SRAS et du H5N1 comme question de sécurité nationale à Taiwan : processus, motivations et conséquences 將SARS、H5N1 設定為台灣國家安全的議題之過程、動機與結果

Vincent Rollet

Introduction

1 Infectious disease epidemics can be framed in a variety of ways. Indeed, they may be considered as a public health and social hygiene issue, as a development issue, as a human rights issue, as a risk management issue or as a security threat. However it is framed, this has its proponents—and sometimes opponents—, its discourses and claims, its modalities and mechanisms of response, its objectives as well as direct and indirect consequences. In 2003 when SARS broke out in Taiwan and in 2005 while avian flu (H5N1) was spreading quickly in Asia, Taiwanese authorities decided to consider and present both diseases as ‘issues of national security’ and consequently adopted responses to these health issues that reflected such framing. This article proposes to examine how SARS and H5N1 were securitized in Taiwan.

2 We start with an overview of the global securitizing dynamic of infectious diseases which helps to position our study in a broader context and with the presentation of our analytical framework inspired by the current international academic debate related to such phenomenon. Then, in a second part, we assess the process through which specific public health issues, namely SARS and H5N1, became issues of national security in Taiwan by asking the following questions: what kinds of actors were the main initiators of this process in Taiwan (entrepreneurs of security)? What are their discourses on

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epidemics, and what was the concrete materialization of such framing and its direct consequences in terms of epidemic control and prevention? Finally, we underline the factors facilitating the securitization of SARS and H5N1 in Taiwan in order to reveal what might explain the success of this phenomenon.

Securitizing infectious diseases: trends and analytical frameworks

Linking infectious diseases to security

3 In order to position the framing of infectious diseases as a security issue in Taiwan in a much wider context, it is worth mentioning that for more than 20 years, interested by the role that epidemics might play on security—notably national security—academics, governments, and international institutions have increasingly granted infectious diseases the status of security issues.

4 At the origin of this process of “securitization”1 of infectious diseases, one finds the development of an “emerging diseases” campaign in the United States in the late 1980s. This marks the end of a period of optimism about the possibility of the total eradication of infectious diseases worldwide, which had been nourished by the discovery of new vaccines and drugs against infective agents in the first part of the 20th century.2 While HIV/AIDS, Hepatitis C and E. coli 0157: H7 had already emerged, this campaign gained in both visibility and in scientific authority thanks to the participation of two of its principal leaders, namely Stephen Morse, a virologist, and Joshua Lederberg, a geneticist and microbiologist, and to the publication of the 1992 Institute of Medicine (IOM) report entitled Emerging Infections: Microbial Threats to Health in the United States which is considered to have been particularly influential on scientific, political and public perceptions of health and security in America in the 1990s’.3 Indeed, after conceptualizing the notion of “emerging diseases” and describing the global and microbial causes of disease emergence, the report emphasizes the consequences of such phenomena, notably in terms of national and global security. The report’s main objective was to convince security experts and decision-makers that infectious diseases had not disappeared and to support their recommendation in various domains of intervention, namely surveillance, training and research, vaccine and drug development, and behavioral change.4

5 The report was considered as conclusive for many, and the emerging diseases movement’s approach rapidly spread through the scientific, public health and medical communities and succeeded in convincing policy and decision makers, security experts, journalists in the United-States and worldwide as well as international organizations such as the WHO.5 This network of individuals and institutions thus played the role of the institutional relay of a scientific vision considering the rise of “emerging infections” as a problem and linking this issue to national and global security. This “emerging diseases worldview”6 culminated in terms of international visibility and acceptance when the UN Security Council addressed the issue of HIV/AIDS in 2000, and adopted—despite initial opposition from Russia, China and France—Resolution 1308 acknowledging the negative impact of HIV/AIDS on security.7

6 Outbreaks of SARS in 2003 and the threat of H5N1 since 1997 strengthened the influence of the approach worldwide and convinced countries such as Australia,

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Canada,8 Singapore, Vietnam, Malaysia, Philippines 9 as well as regional organizations such as the European Union (EU) and the Association of South-East Asian Nations (ASEAN)10 to grant emerging diseases the status of a ‘security issue’. Simultaneously, epistemic communities produced a growing number of scientific books and articles, and developed research programs to conceptualize and illustrate the link between such diseases and security,11 with the aim of helping decision-makers define the problem and identify policy solutions.

7 Two other important dynamics have been shaped by, and then incorporated into the “emerging diseases worldview.” First, the US government had been examining the biosecurity response to a possible anthrax or smallpox attack since the late 1990s, and this mobilization intensified in the aftermath of 9/11. The local/national consequences of global health and biological events came under the spotlight, reinforcing the idea that assisting other countries to face health-related challenges was in the US national interest. It also highlighted the threat posed to national security by international transportation and trade potentially facilitating the rapid spread of infectious diseases in a globalized world.12

8 The second dynamic is the debate on the impact of infectious diseases on human security. This started with the publication of the 1994 United Nations Development Program (UNDP) Human Development Report which considered that challenges such as global infectious diseases were “critical pervasive threats to human security,” notably because they jeopardize health security as well as many other components of the human security agenda such as economic security, food security and community security.13 This people-centered approach to security (human security) in the domain of health, as opposed to a state-centered approach (national security),14 reassured those who had agreed to consider “emerging diseases” as a security issue but who were suspicious of the narrow focus on national security

Assessing the securitization process for infectious diseases

9 With the aim of determining how and when a specific issue becomes a security issue, securitization theorists in the field of International Relations proposed to “explore the logic of security itself to find out what differentiates security […] from what is merely political.”15 They then concentrated their efforts in assessing the securitization process or the process by which an issue is presented as “an existential threat with a saliency sufficient to have substantial political effects.”16 Most of these scholars agreed that five main elements determine a securitization process. 1. The securitizing actors who frame an issue as a security issue. These ‘entrepreneurs of security’are generally perceived as “accepted voices of security, by having the power to define security”17 and while it is not always the case, are often government officials, political leaders or lobby groups. 2. They produce a securitizing discourse presenting the specific issue as an existential threat. The word “security” per se may or may not be used by securitizing actors, but arguments to frame the issue as a threat will be critical. 3. A referent object is designated as the potential victim of such an existential threat. 18 This referent object may be the State (national security)19 or, thanks to the vertical enlargement of the concept of security, it could also be the World (global security), a region (regional security) or individuals (human security).

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4. Exceptional measures, different from measures taken in the context of the routine political management of a non-securitized issue, are actually implemented (and not mere rhetoric). 5. Securitization also depends on whether the audience toward which the securitizing discourse is directed, accepts, refuses or resists the issue being framed in this way.20 As some scholars have underlined: “Security (as with all politics) ultimately rests neither with the objects nor with the subjects but among the subjects.”21 Securitization theorists require the effective implementation of exceptional measures and the acceptance of the targeted audience as concrete elements of the securitization process. If no sign of acceptance is found among the targeted audience, they prefer to talk about securitizing moves.22

10 Therefore, the process of securitizing a specific issue relies first on “speech acts”23 or statements that have performative functions: a securitizing actor declares that a specific issue represents an existential threat toward a referent object and that, in the context, it is required to adopt exceptional measures. Then, only if the discourse is accepted by the targeted audience and materialized into concrete exceptional measures, is it possible to consider the securitization of the specific issue as tangible.

11 This securitization process has facilitating conditions24 if the speech act is produced by an actor possessing a position of authority to talk about security and when the issue is considered threatening.25 Political legitimacy; the desire to strengthen control on society, notably in non-democratic countries26; the will to retain authority and privilege,27 as well as pressures from international and/or domestic spheres 28 may represent strong incentives to frame a specific issue as a security issue. The domestic political, social, cultural and economic context of the securitizing actor as well as their position within the international community at that time may influence such a process. 29

12 Simultaneously to this international relations framework, the securitization of infectious diseases has also been studied by anthropologists who positioned the securitization of infectious diseases in the long term. Such historical perspective helps, thus, to emphasize similarities and differences between the “emerging diseases worldview” and earlier medicine and public health ideologies, thereby showing that the link between national security concerns and public health is not new.30 Distinctions are made between “sovereign state security” developed in the 17th century and calling for the protection of territorial sovereignty against foreign armies, “population security” emerging in the 19th century and resting on the idea of protecting the national population against domestic threats and, finally, “vital systems security” central to the contemporary politics of security in the domain of health, whose objectives of protection are the essential structures governing social and economic life. 31 While an approach to infectious diseases in terms of population security generates preventive measures, considering such a health challenge as an issue of vital systems security generates preparedness initiatives.32 However, these two types of measures are profoundly different. Developed in the 19th century, prevention policy notably relies on an extensive and scientific understanding of specific infectious diseases and on the probability of contemporary outbreaks. In this context, preventive measures which aim to protect the population are materialized by public health initiatives or developmental measures against poverty.33 Conversely, preparedness, as an “emergency modality of intervention,”34 deals with generic health events of very low probability and uses fictions to reinforce its legitimacy: it is instead materialized by measures which aim at addressing vulnerabilities in health infrastructure, such as the strengthening of multi-

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level disease surveillance systems, the development of scenario-based exercises,35 the production of vaccines or the stockpiling of medicine. In that way, preparedness measures are implemented with the objective of strengthening the capacity of a country to respond to any potentially catastrophic biological event.36

13 Finally, regarding the outcomes of the contemporary securitization process of infectious diseases, positive and negative impacts have been underlined in academic literature. Indeed, on the one hand, it has been illustrated that securitizing a particular disease may raise the profile of the disease,37 helps to mobilize human and financial resources to a level that other framing would not be able to reach and represents a critical approach to responding efficiently to epidemics.38 However, on the other hand, scholars have also pointed out that securitizing a disease may divert limited resources to one specific health problem and away from others. It might also run against the preventive risk management strategy that is needed to address infectious diseases, by stimulating a preference for preparedness measures. Finally, it has also been emphasized that such a securitization process contributed to international virus- sharing disputes between developing and developed countries, as in the case of Indonesia’s decision in December 2006 to cease sharing its H5N1 virus samples in the name of national security.39

14 In this article, we propose to use both approaches complementarily in order to assess the securitization of SARS and H5N1 in Taiwan. Taiwan is an interesting case, as the country was very close geographically to the epicenter of the SARS and H5N1 outbreaks and, at the time, neither belonged to nor had observer status at the WHO. In deconstructing the dynamics of securitization of SARS and H5N1 in Taiwan, we intend to shed light on their securitizing actors, their referent objects and the rhetoric used to present both diseases as existential threats. The objective of this study is also to appreciate the material and ideational outcomes of such securitization in terms of exceptional measures and of infectious disease management. Finally, this contribution aims to reveal the motivations—or facilitating conditions—behind the securitization of these two infectious diseases, as well as the cost and benefits of such actions.

Securitization of infectious diseases in Taiwan: SARS and H5N1 as case studies

The Taiwanese breeding ground for infectious diseases securitization

15 In the 1960s, Taiwan, the United-States and the WHO40 shared the optimistic idea that infectious diseases were being increasingly well managed.41 This general conviction, which continued until the beginning of the 21st century, was supported by a real decrease in the incidence of infectious diseases such as tuberculosis, Japanese encephalis and hepatitis A in Taiwan, as well as the eradication of bubonic plague (1948), filariosis (1955), rabies (1959), cholera (1964), typhus (no reports of any cases since World War II), smallpox (1965), malaria (1965)42, diphtheria (1981) and poliomyelitis (1985) on the island thanks to the progressive reconstruction of the Taiwanese public health infrastructure—notably supported by the United States—43 and the implementation of preventive measures. This optimism was further reinforced by the recognition of these successes by the international community, particularly the

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United-States (the US Agency for International Development (USAID)44 and the US Congressional Taiwan Caucus),45 WHO, 46 APEC 47 as well as think-tanks such as the Center for International Development at Harvard.48 As an institutional consequence of such confidence in the fight against infectious diseases, the network of infectious disease control in Taiwan was largely replaced by a disease control system mainly dedicated to chronic diseases.

16 Interestingly, in this context of general optimism in Taiwan, neither HIV/AIDS which increased from 9 to 5,650 cases between 1984 and 2003 nor the augmentation of tuberculosis infecting 15,042 people in 2003 (11,591 cases in 1996) convinced the Taiwanese authorities to consider the rise of infectious diseases as a problem, even if some scientists started to point out the necessity of doing so.49 However, the Enterovirus 71 (later abbreviated to EV71) crisis in 1998 changed the situation and represents a turning-point for two main reasons. First, with 78 deaths, the EV71 crisis was more visible internationally than HIV/AIDS or tuberculosis. As a consequence, foreigners started to criticize the official response to the crisis and to question the capacity of Taiwan to deal with infectious diseases in general.50 Second, the Taiwan Department of Health asked the US CDC (Centers for Disease Control and Prevention) for assistance in monitoring and controlling the outbreak.51 After several meetings between the delegation and Taiwanese authorities to discuss control measures and after criticism by the US CDC on the disorganization of the infectious diseases control system in Taiwan—particularly the lack of autopsies, which made it impossible to know whether the victims actually died of the EV7152— some changes indicate the progressive acceptance by the Taiwanese authorities of the “emerging diseases view” supported by the CDC.

17 First, a Taiwan CDC was created on July 1st, 1999 to enhance the management of epidemics in Taiwan, and replaced a number of institutions charged with disease control: the Bureau of Communicable Disease Control (BCDC), the National Quarantine Service (NQS) and the National Institute of Preventive Medicine (NIPM), all vividly criticized during the EV71 crisis for their lack of coordination.

18 Second, after 1998, Taiwan reinforced its enterovirus surveillance capacity by strengthening its national diseases surveillance structure, until then based only on a sentinel surveillance system. Taiwan then developed a website version of the notifiable disease surveillance system (1999), a school-based surveillance system (2001) and a syndromic surveillance system (2002) which confirmed a move to disease surveillance that is a characteristic of preparedness, in contrast to other public health methods focusing on the surveillance of diagnosed individuals.53 Taiwanese health authorities also actively started epidemiological research and vaccine development with an EV71 prototype vaccine, conducted training for health professionals to improve diagnoses, cures and preventative methods against enterovirus infection, and encouraged behavioral changes such as frequent hand washing.

19 The second dynamic for infectious diseases securitization in Taiwan is the link between biological war, bioterrorism and the (re)-emergence of infectious diseases. Concerns in Taiwan about a biological attack started during the Cold War in the context of the development of biological weapons in China and was still evoked by the Ministry of National Defence in 200054 as well as by the President of Taiwan, Chen Shui-bian55 and by the director-general of the CDC in 2002.56 Two anthrax attack false alarms in October 2001 took place just one month after an anthrax incident in the United States

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(September 18, 2001). At the same time, bioterrorism was at the center of the discussions at the fourth emergency high-level National Security Meeting held after the September 11th attacks, was considered by the CDC to be a national defense issue and was the topic of numerous academic articles.57 In the “2002 National Defense Report” published by the Ministry of National Defense, a section was dedicated to the presentation of a mechanism of epidemic management whose main objective was to protect those Taiwanese soldiers considered key for national security against any outbreak of infectious diseases.58

20 Thus, thanks to progressive acceptance by Taiwanese officials of the “emerging diseases worldview” and the construction of a direct link between infectious diseases and national security in the context of the response to biological warfare, bioterrorism and outbreaks of infectious diseases within the Taiwanese army, a breeding ground was prepared to facilitate the securitization of emerging diseases such as SARS and H5N1.

Framing SARS as a national security issue

21 SARS was first identified in China in November 2002 and entered Taiwan via a traveler from that country on March 15, 2003. Then the disease spread in two stages. During the first period, from March 15 to April 19, 2003, 78% of probable cases were travel-related, 16% occurred in households and among social contacts of SARS cases and 6% were hospital-acquired.59 With the support of the US CDC, who sent experts to Taiwan on March 16 following a request from the Taiwanese government to the WHO, Taiwanese authorities succeeded in containing the epidemic as a first step. As a symbol of this success, the first International Symposium on SARS was organized in Taipei (April 21) and gave the opportunity to the authorities to share their victory with representatives from the international community. However, ironically, on the day after the event, the epidemiological situation worsened following the misdiagnosis of a patient infected with SARS at the Taipei Municipal Hoping Hospital.60 From that day (April 22) to the end of May, with seven outbreaks of SARS in different medical institutions in northern and southern Taiwan, the second phase of the spread of SARS in the country was characterized by the fact that 89% of cases were hospital-acquired, 9% travel-related and only 2% community-acquired.61 On April 27, Taiwan had its first SARS fatality, while the total number of SARS cases reached 339. On May 3, the WHO decided to send two experts to Taipei. After the implementation of various epidemic control measures, the spread of SARS was finally halted at the beginning of June 2003 after more than 600 Taiwanese had been infected by the disease since its arrival in the country. The outbreak killed 81 people. After containing what has been called the “Chinese syndrome” or the “21st century’s first great epidemic,”62 Taiwan was finally declared a “Sars-free zone” by the WHO on July 5.

22 In Taiwan, the process of securitizing SARS started very quickly after the announcement of the first case in the country. Among the main actors of this social construct, President Chen Shui-bian was certainly one of the first to securitize SARS publically. Indeed, in early April 2003, during his opening remarks to the International Seminar on Asia-Pacific Cooperative Security, President Chen stated that SARS should be considered “with the same urgency applied to the defense of national security.”63 Then after April 21, with the growing number of SARS cases in the country, the disease obtained the official status of an issue of national security. A few days after the first

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SARS-related death in Taiwan, President Chen convened a ‘High-Level National Security Meeting on SARS’on May 1, 2003. During this meeting, he announced a number of policies with the intention of defending what was then considered a major potential victim of a SARS epidemic, namely the State. The measures related to epidemic control, public morality, industrial and economic ties between Taiwan and China, and wider international cooperation.64 Indeed, while protecting the health of the general population was mentioned during the meeting, the main objective of the measures adopted was to protect the State and more precisely the key infrastructure, critical to maintaining economic and political order, notably by assisting industries seriously affected by SARS, reducing panic among the public through transparent communication and strengthening the capacity of hospitals to deal with the disease. Simultaneously, in a context of international concern over Taiwan’s response to SARS,65 control measures recommended by WHO and US CDC teams during their visit to Taiwan were scrupulously implemented by Taiwanese health authorities. Thus, health authorities closed all SARS-affected health-care facilities to new admissions, restricted visiting to the affected facilities and implemented universal temperature screening and monitored staff absences. They also asked that patients discharged from such facilities during the incubation period should be notified of the need for fever monitoring, restricted the transfer of patients between health-care facilities and assembled Taiwan CDC teams to conduct on-site investigations.

23 Furthermore, health authorities reinforced the national epidemiological surveillance of SARS by granting it notifiable disease status, ran public campaigns to accelerate the diagnosis and reporting of people showing symptoms. They also raised public awareness of respiratory hygiene and appropriate health-seeking behavior in cases of a persistent fever and/or a dry cough, implemented exit screening at air, land and sea borders and issue health advice in writing to departing passengers.66 Methods recommended by the WHO but whose effectiveness were unproven were also implemented, such as the closure of department stores.67

24 The unprecedented Presidential initiative which officially granted SARS the status of a national security issue also stimulated several exceptional measures aimed at responding to what was then considered an existential threat to Taiwan’s national security. A special NT$ 50 billion (€ 1.25 billion) budget supporting the country’s anti- SARS campaign was approved by the Legislative Yuan: it was the first time that such a giant budget plan had cleared the legislative floor (and in only eight days of debate).68 The money was mainly dedicated to strengthening Taiwan’s preparedness capacity: a very small amount directly targeted the “security of the population.” NT$ 29.8 billion (€ 745 million) was injected for SARS-preparedness efforts and related medical expenses and NT$ 20.2 billion (€ 505 million) to combat the economic impact of the outbreak. Within this budget, NT$ 2 billion (€ 50 million) was reserved for the National Science Council to conduct medical research into the disease, including the development of vaccines and other medicines. The exceptionality of such initiative is also manifest when its total budget is compared to the NT$ 3 billion reserved for the prevention and control of HIV/AIDS, which then infected around 6,000 people.69

25 Another illustration of these exceptional measures is without doubt the official decision to use quarantine as a public health tool to prevent infectious diseases, notably because other preventive interventions (e.g., vaccines and antibiotics) were unavailable. Indeed, after March 18, anyone who had been in close contact with a SARS patient was

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quarantined for 10-14 days. At the end of April, in response to the growing epidemic, Taiwan health authorities implemented a more widespread use of quarantine and by the end of the health crisis, 131,132 people had been quarantined in Taiwan.70 People under quarantine were required to stay in the immediate locality to where they were diagnosed, monitor their temperature, and seek medical attention if they had fever or other respiratory symptoms. There were various levels of confinement, and depending on these, sufferers could leave quarantine only for activities authorized by the local health authorities such as seeking medical attention, exercising outdoors and purchasing food. They were not allowed to use public transport, visit hospital patients, or crowded public places and had to wear surgical masks when around other people and when outside the quarantine site. The high-security aspect of such measures was reinforced by the introduction of a fine of between US$ 1,765 and US $ 8,824 and the risk of incarceration of up to 2 years in cases of non-compliance with quarantine regulations including submitting incomplete SARS survey forms or inaccurate contact information. Police officers were stationed outside the quarantine facilities in order to ensure compliance. Little sign of resistance to these measures was noted, with only 286 people (0.2% of those quarantined) being fined for quarantine violations.71 Taiwan was one of several countries that implemented quarantine measures during the global SARS outbreak. Not only do such initiatives, which clearly demonstrate state power in time of crisis72 remain extraordinary in the sense that they place “limitations on otherwise inviolable rights,”73 namely the freedom of movement in a democracy such as Taiwan, they are also generally considered as an archaic method of protecting public health.74

26 Parallel to the exceptional measures detailed above, other atypical and smaller scale initiatives have also fed into the impression of a close and direct link between SARS and Taiwan’s national security, notably due to their nature or the resources they mobilized. Among these measures, one can mention the mobilization of 1000 soldiers, 150 members of the military police, as well as 55 special military vehicles used for disinfection by the Taiwan Ministry of National Defense in order to help the country control the spread of SARS.75 The Ministry of National Defense’s interventions on the epidemic were closely followed by the Taiwanese media through the 24 hour TV news programs and the print media. The government chose the military-run Institute of Preventive Medical Research to develop a vaccine against SARS76 and the Songshan Armed Forces Hospital (affiliated to the Ministry of National Defense) became the first hospital devoted to treating and caring for SARS patients.77 At that time, the TV news and newspaper pictures showing military-uniformed nurses caring for SARS patients were reminiscent of those seen in times of war.

27 Finally, to illustrate this securitizing environment, one could certainly mention the daily televised Taiwan Department of Health press conferences, similar to those organized by the US and UK military forces during the Iraq war which occurred around the same time. During these routine events, measures taken by the government were presented as the weapons in a “war against the enemy” (Yichang duikang diren zhanzheng).

28 The securitization of SARS in Taiwan relied on the fact that the President and government of Taiwan (securitizing actors) presented SARS to the public as an existential threat to national security—notably to vital systems security—(referent object) and concluded that the situation necessitated strong action (exceptional measures) in order to prevent and contain the disease. These extraordinary measures

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were truly and sustainably implemented and largely accepted by the target audiences, namely the members of the Legislative Yuan for the approval of the special SARS budget, and the citizens who had been in close contact with SARS patients for the quarantine. The securitization of SARS also reveals the increasing prominence given to “emerging diseases” by Taiwanese government officials and, in the light of the control and the preparedness measures taken in response to the disease, it also confirms the progressive acceptation in Taiwan of the “emerging diseases worldview” promoted by the US and the WHO. As we will now see, these two dynamics were amplified by the securitization of H5N1.

Granting H5N1 national security issue status

29 With the exception of Brunei, Singapore and the Philippines, all Taiwan’s neighbors have been affected by H5N1 since 2003 and at least nine Asian countries have reported human cases of the virus. However in Taiwan no human cases of H5N1 have been identified so far, even though the country possesses very close trade and touristic relations with most of the infected countries in Asia.

30 Nevertheless, the possibility of an H5N1 outbreak in Taiwan has not been ignored by health authorities. As an illustration, in March 2005, 42 deaths attributed to H5N1 in neighboring countries prompted the Taiwan CDC to declare that “a bird-flu epidemic is (just) a matter of time”78 and, in March 2006, when an H5N1-related death was reported in Southern China, the Department of Health (DOH) chief Hou Sheng-mou declared that “the threat of bird flu is approaching the gates of Taiwan.”79

31 Taiwanese health authorities continued to promulgate this alarming message80 which at one and the same time raises the potential of an H5N1 outbreak in Taiwan and proclaims the fact that there had been no human cases of H5N1 in the country due to the efforts of the health authorities.

32 In such a context, H5N1 was considered a security issue in Taiwan from August 19, 2005, when President Chen Shui-bian convened a new National Security Council meeting to discuss a prospective analysis published by the US CDC predicting 14,000 Taiwanese deaths in the event of an H5N1 outbreak and calling for stronger preparedness measures.81 On October 31, 2005 and March 9, 2006, President Chen convened the second and third High-Level National Security Council meetings on avian flu, which he described as “a serious threat to both social stability and national security.”82 He explained in 2006, during a videoconference with European officials : My administration attaches great importance to the prevention of avian flu. I personally convened a high-ranking national security conference in August 2005 to discuss issues related to avian flu. Since then, we have convened two more national security conferences to discuss this important issue, which is to say, that the Taiwan government has upgraded the issue of avian flu epidemic prevention and control to the national security level.83

33 In its ‘Strategy plan for the execution of an influenza pandemic response,’ the Department of Health classified avian flu as “a non-traditional security threat” and warned that an outbreak of H5N1 would not only represent a catastrophe for public health and for the agricultural sector, but also “a great threat to social stability and national security.”84 Moreover, Council of Agriculture (COA) Chairman Lee Chin-lung underlined that “avian flu control has been raised to a national security level”85 and the representative to the European Union and Belgium and former senior advisor of the

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National Security Council, Michael Kau Ying-mao, explained that “our experience with SARS a few years ago helped us to learn how to manage a public health emergency and we consider avian flu as a threat to national security.”86

34 The decision to respond to the potential spread of H5N1 as a national security issue engendered several preparedness measures aimed at protecting Taiwan’s “vital infrastructure.” Indeed, as for SARS, a special and impressive budget of NT$ 30 billion (€ 751 million) supporting control measures was accepted without any disagreement from the opposition-dominated Legislative Yuan.87 While concerns about a potential outbreak of H5N1 in Taiwan certainly motivated such immediate support from the Yuan, the fact that the government also argued for the budget on its multi- disease coverage and “dual-use”—as it would simultaneously help to strengthen Taiwan’s response to bioterrorism—certainly helped convince the Yuan that even if there was no H5N1 outbreak in Taiwan, the budget wouldn’t be a waste of money. To appreciate the exceptionality of such a financial initiative, it might be revealing to highlight that in 2005 the DOH invested NT$ 416 million in cancer prevention, the leading cause of death in Taiwan since 1982.88

35 After the inclusion of H5N1 as a notifiable disease in Taiwan (December 2004) and the adoption of the H5N1 budget, preparedness measures recommended by the WHO and the US CDC were strictly implemented in Taiwan within the framework of the five-year National Influenza Pandemic Preparedness Plan (2005). Systems for the surveillance of populous institutions and information collection for infectious diseases were added to the national disease surveillance system. The capacity of critical structures such as hospitals to control nosocomial diseases and avian flu was also strengthened through training health professionals and increasing the quality and number of negative- pressure isolation rooms. Furthermore, a National Health Command Center (NHCC) (Guojia weisheng zhihui zhongxin), largely inspired by the US Health Command Center, was created within the Taiwan CDC in 2005 in order to unify the national response to major man-made and natural epidemics.

36 Fruit of some exceptional initiatives, stockpiling antivirals was another weapon in the Taiwanese preparedness arsenal against H5N1. Indeed, in October 2005, Taiwan had enough Tamiflu to cover only 4% of the population at a time when the WHO recommended coverage of such a stockpile should be 10%. As the government was concerned about Roche’s effective production and dispensing capacity of at a time of global pandemic, the DOH sent a request to the Swiss company—then the only producer of such an antiviral—for a secondary license allowing Taiwanese private companies working with the National Health Research Institute to mass-produce Tamiflu to increase the country’s stockpiles as a precautionary measure against a potential avian flu pandemic.89 Having not received a positive answer from Roche and in order to prove both domestically and internationally that Taiwan was able to produce such a drug, the DOH, which had one month earlier asked the Taiwan National Health Research Institute (NHRI) to evaluate the possibility of producing Tamiflu in small quantities, announced on October 18, 2005 that Taiwan was able to develop a generic version of Tamiflu which was 99.9% identical to Tamiflu.90 During the second national security meeting on avian flu,91 the President of Taiwan declared the making and stockpiling of antiviral drugs to be ‘the work of utmost important regarding the disease’. One day later, on November 1, the DOH submitted an application for a compulsory license92 to the Taiwan Intellectual Property Office (IPO) to obtain the authorization to manufacture a generic version of

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Tamiflu locally without the consent of the patent holder, as is allowed under WTO regulations in the context of medical emergencies.93 While waiting for answers from the IPO and from Roche, the DOH decided to purchase three tons of shikimic acid, a product made in China essential in the manufacture of Tamiflu.94 Finally, at the end of November 2005, Roche had still not answered the Taiwan DOH’s request, and after receiving the authorization from the IPO, Taiwan health authorities decided to use the “compulsory license” in order to produce their generic Tamiflu and reach the recommended coverage level of 10% of the population. However, in order to prevent damage to Taiwan’s image in the protection of intellectual property rights, the authorization to manufacture this anti-viral drug without the consent of Roche was only accepted by the IPO under several conditions. The compulsory license was limited to domestic use and effective to the end of 2007. Furthermore, Taiwan could only start production of Tamiflu when its stocks and those ordered from Roche were depleted.95 In fact, Roche provided Taiwan with additional doses of the anti-viral in 2006, which allowed the country to cover 2.3 million people (10% of the whole population). By the end of 2007, Taiwan was free of H5N1; it thus did not need the Tamiflu that the government had in its stock, and local mass-production of a generic version of Tamiflu was never launched. It is noteworthy that the decision to issue a compulsory license for Tamiflu is exceptional. Taiwan was the first country to have employed such a mechanism to ensure sufficient stockpiles of the drug in case of a pandemic.

37 Consistent with the preparedness approach, which in contrast with classic public health uses imaginative techniques to simulate potential health threats, the Taiwanese government also conducted table-top exercises based on various catastrophic scenarios in order to reveal and address weaknesses in its critical infrastructure.96 Thus, major flu epidemic training exercises were held in Pingtung County by the CDC in 2006 and 2007 in conjunction with the Wan-Ann Military Exercise organized by the Ministry of National Defense and within the framework of a cooperation agreement between that Ministry and the CDC. The CDC also organized the “Egret Number 1” flu-exercise to test the off-shore medical care system based on serious H5N1 influenza pandemic scenarios with high fatality levels.97

38 Similarly to what had occurred during the SARS episode, the above events confirmed the H5N1securitization process. Indeed, this virus—for which there were no human cases reported in Taiwan—had been considered and presented as an existential threat to national security—more precisely to Taiwan’s vital systems security—by the Taiwanese authorities who consequently decided and implemented, without domestic resistance, exceptional preparedness initiatives.

Facilitating conditions and consequences of the securitization process of SARS and H5N1 in Taiwan

Facilitating conditions: domestic politics and international factors

39 Securitization theorists use the term facilitating conditions for factors explaining the acceptance of a specific concern as a security issue. Looking at such conditions might help us to understand why SARS and H5N1 have been securitized while diseases whose morbidity and mortality incidences are higher, have never been considered security issues, as well as to appreciate the origins and incentives behind such an approach.

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40 While President Chen Shui-Bian was in a position of authority to talk about security, as he represented, at that time, the highest authority in Taiwan, other factors facilitated the securitization process of these two diseases. Domestic politics is one of these factors. In 2000, the election of Chen Shui-bian of the Democratic Progressive Party (DPP) and former mayor of Taipei, ended more than fifty years of Kuomingtang (KMT) control of the government whose political legitimacy rested notably on its capacity to bring economic prosperity to the country through the rapid industrialization and economic growth in the 1970s and 1980s. During his presidential campaign, Chen Shui- bian promised to consolidate Taiwan’s democracy, to fight corruption and to defend fair and open social welfare policies, and also pledged to pursue economic development and to raise Taiwan’s economic competitiveness. This last pledge was often ridiculed by the KMT and a survey in 2000 showed that only 12.3% of the respondents considered that Chen was the most competent candidate to deal with economic growth while the KMT candidate, Lien Chan, reached 35.7%. In other words, although legitimated by the ballot box through universal suffrage, Chen and his government had also to gain political legitimacy through economic growth. Before SARS broke out in Taiwan on 22 April 2003, Chen Shui-bian’s government had actually been successful in keeping to its economic objectives, as Taiwan’s economic growth had reached 3.54% (-2,1% in 2001, 3.2% in 2002) making Taiwan the second-fastest growing of Asia’s dragon economies after South Korea.98 Furthermore, Chen Shui-bian and the DPP were already involved in the campaign for the next presidential election, which would be held eleven months later (March 20, 2004). In this political context, with SARS cases being reported in Taiwan and economic forecasts revealing that the outbreak could damage the whole economy99 and tarnish his presidential mandate, Chen Shui-bian decided to grant this specific health issue the status of an issue of national security. This was also intended to influence the 44.1% of voters in 2000 who still thought that he was not the most competent person to deal with the issue of economic growth.100 In other words, political legitimacy and electoral strategy also motivated the securitization of SARS.

41 Similarly, domestic politics also played a facilitating role in securitizing H5N1. In August 2005, when H5N1 had been officially granted the status of an issue of national security, Chen Shui-bian had also been reelected—by less than 30,000 votes—and while the global economy had entered a phase of slower growth, Taiwan’s economy remained on a path of stable growth reaching an annual rate of 4.1%.101 The DPP government had thus proved that it was able to provide sustainable economic growth in Taiwan as Chen had promised in 2000 and repeated during the 2004 presidential campaign. However, at that time, Chen and his government knew that the forthcoming local elections (December 2005) would be a real test for them as the rate of unemployment was rising and a series of scandals had tarnished the DPP’s image. The threat of the outbreak of a disease devastating Taiwan’s economy—as was forecast by numerous economists in Taiwan and abroad—led Chen and his government to take exceptional measures, showing their determination to protect Taiwan’s vital infrastructure and people against this potential pandemic and at the same time reassuring the voters about the efficiency of their policies. The only mechanism which could allow the rapid acceptance by the Legislative Yuan and the implementation of such initiatives was to make H5N1 an issue of national security. In other words, even though the DPP was later replaced by the KMT as the largest party at a local level, securitizing H5N1 during the post-election period was an electoral strategy by the government with the aim of

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strengthening its image of being in control of the situation and convincing voters to support its candidates in the local elections.

42 International politics, characterized by the will to clearly differentiate Taiwan from China (PRC), has also played a crucial role in this dynamic. Furthermore, considering pandemics as threats and not as risks, amounted to attributing the responsibility of such a health event to an identifiable source and not to consider its occurrence as an unintended consequence of global, regional or local dynamics.102 Indeed, SARS was clearly and repeatedly identified as originating from mainland China by Taiwanese authorities.103 SARS was presented by President Chen as “an imported disease” from China,104 its presence in Taiwan as similar to the existence of Communist Chinese spies in the country, according to the DOH,105 and its occurrence on the island was explained by Chen as the direct result of a Communist Chinese cover-up of the epidemic.106 Such identification of the PRC as the source of the disease was repeated in the context of H5N1 when President Chen painted China as a “black-hole in the global effort to prevent avian flu”107 and when Mainland Affairs Council Vice-Chairman Liu Te-Shun explicitly stated that the lack of transparency in China’s epidemic disease information on H5N1 was jeopardizing Taiwan’s disease prevention efforts and was putting the health of the Taiwanese people at risk.108 While this deliberate choice to accuse the PRC as the source of both epidemics does not come as a surprise from a pro-independence president such as Chen Shui-bian or for government officials affiliated to the DPP, it helped to stir Taiwan nationalism both among DPP supporters and elsewhere and to reinforce the images of an authoritarian PRC versus democratic Taiwan. Interestingly, by contrast, in 2013, the KMT government and President Ma Ying-jeou did not frame H7N9 as an issue of national security, but as a risk. At the same time the Taiwan Solidarity Union (TSU, Taiwan tuanjie lianmeng), a political party advocating Taiwanese independence, did express the necessity of doing so.109

43 Framing SARS and H5N1 as issues of national security was also a way for Taiwan, who was not and still is not a member of the WHO, to reinforce its identity at the global level. Indeed, by following this international trend of securitizing emerging diseases, by reforming its epidemic control infrastructure and developing its strategies in reference to what has been done by the US CDC—itself a global institution—and by scrupulously implementing the control and preparedness measures recommended by the WHO in response to SARS and H5N1, Taiwan has identified itself as a member of the global health security community.

Consequences of the securitization process of SARS and H5N1 in Taiwan

44 In the case of the securitization of SARS and H5N1 in Taiwan, three main and direct consequences of such an approach can be underlined.

45 First, it had an institutional effect. Indeed, the framing of a health issue as a national security issue actually invited the Department of Health—which was then not even a full Ministry – and its affiliated agencies, such as the CDC, to play in the yard of “high politics.” This opportunity certainly helped the DOH to upgrade its institutional position within the government as well as its power relative to other ministries. This helped the DOH in its request to be granted a ministerial status and more recently (July 2013) in its expansion to become the Ministry of Health and Welfare.

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46 The second important consequence of addressing these emerging diseases as an issue of national security and not as an issue of population security is the replacement of a logic of prevention for a logic of preparedness, focused on safeguarding the security of Taiwan’s vital systems security. In other words, SARS and H5N1 have profoundly changed the way Taiwan responds to epidemics. The progressive acceptance of the preparedness approach by Taiwanese officials in dealing with epidemics is revealed by the institutional health reforms introduced after the 2003 SARS outbreak (creation of a Taiwan CDC, strengthening the national epidemiological surveillance system) as well as by the measures implemented to keep Taiwan free from H5N1 (training health professionals, table-top exercises, stockpiling Tamiflu and a vaccine research program). This approach was confirmed in the National Influenza Pandemic Preparedness Plan and in the Influenza Pandemic Strategic Plan whose main objectives are according to the CDC, to minimize the death toll, economic losses and the impact of new influenza viruses.110 Such choices raised questions about their consequences in terms of the respect of human rights in Taiwan in the case of a major epidemic, given the fact that experience in Taiwan and elsewhere reveals how the protection of national security can easily be used to legitimate unfair, non-transparent, invasive, punitive and forced measures.

47 The third consequence touches on Taiwan’s foreign policy in relation to health. Indeed, following the securitization process of SARS and H5N1, Taiwan has implemented several new overseas health initiatives. These have been motivated by the idea that the threat to Taiwanese national security represented by a pandemic might be attenuated through external activities such as epidemic control in the countries where outbreaks of infectious diseases have already occurred.111 Such an approach was coherent with the emerging diseases campaign discourse which was convinced that assisting other countries to face health-related challenges was in the national/regional interest of the helping country/regions.112 Within the framework of such an approach, in 2005 Taiwan started to send medical teams—physicians, epidemiologists, laboratory scientists, vector control specialists and epidemic investigators—to countries where avian flu had occurred, and in doing so brought assistance and guidance in epidemic preparedness and control. Thus, Taiwan sent health specialists to and Chad in 2006 to help these two diplomatic allies manage H5N1113 and donated preventive materials (Tamiflu and protective masks) to Vietnam and in order to strengthen their H5N1 prevention capacities.114 Considering such pre-emptive measures as a success, the DOH institutionalized them through the establishment of the Global Outbreak Assistance Corps of Taiwan or GOACT (Jingwai fangyi dadui) in June 2007, whose main objective is to improve Taiwan’s disease prevention capabilities and to pursue the strategy of “epidemic prevention before domestic outbreak.”115 Considered as the main actor in Taiwan’s “preventive diplomacy against infectious diseases,”116 GOACT has since sent its teams worldwide to participate in disease prevention operations against infectious diseases (Haiti, Indonesia), has closely monitored specific diseases (H1N1 in Hong Kong, China and Mexico) and shared surveillance information with other countries (Australia)117. Such initiatives are not dissimilar to—and have even been inspired by118— the initiatives taken by the US CDC Global Disease Detection and Emergency Response Division and the European CDC to monitor infectious diseases worldwide and to send epidemiological teams abroad to assist foreign countries in outbreak response and preparedness activities with the aim of preventing health crises

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anywhere in the world that might have an impact on the United-States or the European Union.119

Conclusion

48 In response to outbreaks of SARS and H5N1, the Taiwanese authorities decided to consider these two diseases as national security issues, as had been done by other countries in the global context of securitizing of infectious diseases. Encouraged by its capacity to generate large popular support as well as significant funding, the Taiwanese government saw securitization as an opportunity to increase awareness in national identity, make electoral gains and strengthen political legitimacy at the domestic level as well as enhance Taiwan’s national identity at the international level.

49 The aim of protecting Taiwan’s national security in the context of SARS and H5N1 led to the application of exceptional measures, and also provoked a profound change in the way epidemics are managed in Taiwan. The preparedness measures developed and implemented were very different from the preventive measures previously used in the country when faced with such health challenges. At the same time, such a change also illustrates how an international norm—epidemic preparedness—originating from the US and largely promoted worldwide by the US CDC and the WHO has been integrated into official Taiwanese strategies against epidemics, and then how such institutions with global reach influence health strategies on a national level. However, given the narrow focus and the negative consequences such a national security approach may have on human rights, finding an alternative response to the threat of an epidemic in a democracy such as Taiwan represents the next challenge in the domain of epidemic control.

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APPENDIXES

Glossary

Chen Shui-bian 陳水扁 Guojia weisheng zhihui zhongxin 國家衛生指揮中心 Hou Sheng-mou 侯勝茂 Jingwai fangyi dadui 境外防疫大隊 Kau Ying-mao 高英茂 Lee Chin-lung 李金龍 Lien Chan 連戰 Liu Te-Shun 劉德勳 Ma Ying-jeou 馬英九 Taiwan tuanjie lianmeng 台灣團結聯盟 Yichang duikang diren zhanzheng 異常對抗敵人戰爭

NOTES

1. Buzan, Waever, de Wilde 1998: 25. 2. Zylberman 2013: 43-79. 3. King 2004: 66. 4. King 2004: 67. 5. Davies 2008: 297. 6. King 2002: 767.

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7. UN Security Council 2000. 8. Davies 2008: 299. 9. Caballero-Anthony 2006. 10. Caballero-Anthony 2008. 11. Among the most representative contributions of such dynamic: CBACI/CSIS 2000; International Crisis Group (ICG) 2001; Chalk 2001; Fidler, Price-Smith, Heymann 2003; IFRI 2005; Garrett 2005; McInnes 2006; Elbe 2007. 12. King 2004: 75-76 13. UNDP 1994 14. Lakoff 2008: 106 15. Buzan, Waever, de Wilde 1998: 4-5. 16. Buzan, Waever, de Wilde 1998: 25. 17. Buzan, Waever, de Wilde 1998: 31. 18. Waever 1995: 48. 19. Waever 1995: 48. 20. Buzan, Waever, de Wilde 1998: 31. 21. Buzan, Waever, de Wilde 1998: 31. 22. Buzan, Waever, de Wilde 1998: 25. 23. Searle 1969. 24. Buzan, Waever, de Wilde 1998: 31-33. 25. Buzan, Waever, de Wilde 1998: 31-33. 26. Vuori 2008. 27. Davies 2008: 297. 28. Curley and Herington 2011: 162. 29. Baringer and Heitkamp 2011. 30. King 2002. 31. Collier, Lakoff 2006: 2-3. 32. Lakoff 2007: 25. 33. Lakoff 2008: 106. 34. Collier, Lakoff 2013: 14. 35. Lakoff 2008: 404; Zylberman 2013: 145-149. 36. Collier, Lakoff 2008: 17. 37. Davies 2008: 297. 38. Ramiah 2006: 162. 39. Elbe 2010. 40. Zylberman 2013: chap. 1. 41. China Yearbook editorial Board 1961: 636; China Yearbook editorial Board 1962: 678. 42. Lin and Liu 2010: 183-203. 43. See Michael Liu’s contribution on malaria eradication in Taiwan in this volume. 44. Jacoby 1966: 107-108. 45. US Congress 2001. 46. WHO recruited numerous Taiwanese experts on tuberculosis, malaria and dengue fever to work as advisers between 1960 and 1972. 47. APEC 2001: 6. 48. Gallup and Sachs 1998: 6. 49. Huang 1994. 50. CNN 1998. 51. US CDC 1998. 52. CNN 1998. 53. Fearney 2005: 5.

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54. Taipei Times: April 13, 2000. 55. Government Information Office, Taiwan: 2002. Conditions of the election of Chen Shui-bian as President of Taiwan and the tense relationship with China will be specifically presented in the third part of this article. 56. Twu Shiing-jer: 2002. 57. For example: Kuo, Chuang 2002; Lin, Wang 2002. 58. Ministry of National Defense 2003: 318-320. 59. WHO/CDS/GSR/GAR 2003: 23. 60. Predecessor of the Taipei City Hospital’s Heping Fuyou Branch. 61. WHO/CDS/GSR/GAR 2003: 23. 62. Greenfeld 2007. 63. Office of the President, ROC (Taiwan) April 4, 2003. 64. Office of the President, ROC (Taiwan) May 1, 2003. 65. Taipei Times May 11, 2003; BBC News May 18, 2003. 66. Twu 2003; WHO 2004. 67. Taipei Times May 18, 2003. 68. Taipei Times May 23, 2003 69. Taiwan CDC 2003. 70. US CDC 2003. 71. US CDC 2003. 72. Tseng, Wu 2010: 267. 73. Buzan, Waever, de Wilde 1998: 24. 74. Zylberman 2013: 396. 75. Taipei Times May 30, 2003; Taiwan Governmental Information Office (GIO) 2005. 76. Taipei Times May, 14 2003. 77. Chou 2010. 78. Taipei Times March 12, 2005. 79. China Post March 11, 2006. 80. Taipei Times January 11, 2006. 81. Taipei Times August 19, 2005. 82. Taipei Times November 1, 2005. 83. Office of the President, ROC (Taiwan) May 19, 2006. 84. Taiwan CDC 2012a: 152. 85. Taipei Times November 19, 2005. 86. The Parliament Magazine April 9, 2007. 87. Chiang 2005. 88. Bureau of Health Promotion, DOH 2005. 89. China Post October 18, 2005. 90. Taipei Times October 18, 2005. 91. Taiwan Governmental Information Office (GIO) 2005b 92. According to the World Trade Organization, compulsory licensing is when a government allows someone else to produce the patented product or process without the consent of the patent owner. It is one of the flexibilities on patent protection included in the WTO agreement on intellectual property—the TRIPS (Trade-Related Aspects of Intellectual Property Rights) Agreement. 93. China Post November 1, 2005. 94. Asia Times October 29, 2005. 95. Taipei Times November 26, 2005. 96. Collier and Lakoff 2013: 14. 97. Taiwan CDC 2007: 47.

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98. Council for Economic Planning and Development (CEPD) 2003: 4 99. Taipei Times April 26, 2003; Taipei Times April 29, 2003; Taipei Times April 30, 2003. 100. Niou and Paolino 2003: 726. 101. Council for Economic Planning and Development (CEPD) 2006. 102. Beck 1999; Giddens 1999. 103. Rich 2005: 71-73. 104. Department of Health 2003. 105. China Post April 1, 2003. 106. BBC News March 30, 2003. 107. Taipei Times March 10, 2006. 108. Taipei Times March 2, 2008. 109. Taiwan Solidarity Union (TSU) 2013. 110. Taiwan CDC 2012b: 35. 111. Rollet 2010. 112. King 2004: 75-76. 113. Taipei Times April 8, 2006; Le Progrès June 14, 2006. 114. Thanh Nien News July 22, 2005; Department of Health 2008: 117 115. Taiwan CDC 2008: 65-68; Department of Health 2008b. 116. Hou 2007. 117. Taiwan CDC 2011: 66-67 118. Taiwan CDC 2008: 65-66 119. US CDC 2012: 4 and 33; ECDC 2006: 8.

ABSTRACTS

Securitizing epidemics has been an approach used by a number of countries and international organizations to frame these health issues and to develop a targeted response to them. This was notably the case in Taiwan for the 2003 SARS and 2005 H5N1 outbreaks, which were both considered as “issues of national security.” After a general overview of the global trends of securitizing infectious diseases and a presentation of the academic debate about these processes, we propose to examine the case of Taiwan by focusing on the main initiators of such phenomena, on their discourses around epidemics as well as on the concrete materialization of such framing. Then, we underline the factors which might have facilitated the securitization of SARS and H5N1 in Taiwan in order to reveal what might explain these successes, and we mention some of its main consequences.

Considérer les épidémies comme un enjeu de sécurité est devenu une approche utilisée par un certain nombre de pays et d’institutions internationales afin de traiter des questions de santé publique et leur apporter une réponse ciblée. Ce fut notamment le cas du SRAS et du H5N1 à Taiwan qui furent tous deux déclarées questions de « sécurité nationale » en 2003 et 2005. Après avoir présenté la dynamique mondiale qui tend à octroyer à un certain nombre de maladies infectieuses le statut d’enjeux de sécurité et le débat académique portant sur ces processus, cet article se propose d’examiner le cas de Taiwan en s’intéressant plus particulièrement aux initiateurs d’une telle dynamique, aux discours de ces derniers sur les épidémies ainsi qu’à la matérialisation concrète d’une telle approche. Il se penche ensuite sur les facteurs qui ont pu

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faciliter la sécurisation du SRAS et du H5N1 dans ce pays afin de mettre en évidence les raisons du succès d’un tel phénomène, pour enfin mentionner certaines de ses principales conséquences.

如何擁有從疾病前之預防到疾病後之抵制的有效醫療研發，這方面的議題已被許多國家與各 國國際組織嚴肅的重視和討論著。這些研究針對了2002年在中國廣東順德首發，擴散至東南亞 乃到全球，直至2003年中期的傳染性疾病－SARS，和從2003年11月，長達至2006年8月最終證 實因另一大傳染疾病－H5N1（禽流感）病毒而歿的中國籍男子死亡事件。這兩大皆曾引起國 際性恐慌的易傳染疾病在各個死亡案例爆發前後，其實在此兩段其間發生了一系列事件，包 括醫護人員在內的多名病患死亡隱情，還有病原微生物的發現及命名…都從來沒被停止的備受 世界各地及媒體的關注。如今透過串連著全球化科技進步的趨勢、醫術介各個著手中的臨床 實驗、與被議論紛紛的相關論文之貢獻中，我們在挑戰該如何戰勝易傳染性疾病的路程漸漸 明朗。然而，此篇文章針對國人因在經過以上兩大全球性傳染病疫潮，迫使醫療學術必須急 於找出治療途徑的這段過程中，它將指出從入門到具有批判性的學術分析，並且回顧那份在 台灣醫界中後來意識務必要發聲的關鍵人、事、物之倡導動機。再者，此文章在檢測對抗 SARS和H5N1的醫療制度下之同時，進而揭示了世界各國對疫情從剛開始的消極態度，到著手 處理去面對，再到抵制蔓延與達到積極撲滅後疫情才最終被逐漸消滅的種種赤裸過成做出公 開、公正的資料分析與有背後實情的揭露。

AUTHOR

VINCENT ROLLET Vincent Rollet earned his PhD in International Relations (Sciences Po, Paris). He is assistant professor at Wenzao Ursuline University of Languages (Kaohsiung, Taiwan) and research associate at French Centre for Research on Contemporary China (CEFC). He has recently published “Is the EU a Global Health Actor? An Analysis of its capacities, involvement and Challenges” (with Peter Chang, in European Foreign Affairs Review, August 2013) and “Négocier l’accès à la santé au niveau mondial : processus, concrétisation et défis de la diplomatie sanitaire mondiale” (Études Internationales, March 2013). Vincent Rollet a obtenu sa thèse de doctorat en relations internationales (Sciences Po, Paris). Il est professeur adjoint à l’Université Wenzao Ursuline des Langues (Kaohsiung, Taiwan) et chercheur au Centre d’Études Français sur la Chine contemporaine (CEFC). Il a récemment publié « Is the EU a Global Health Actor? An Analysis of its capacities, involvement and Challenges » (avec Peter Chang, dans European Foreign Affairs Review, août 2013) et « Négocier l’accès à la santé au niveau mondial : processus, concrétisation et défis de la diplomatie sanitaire mondiale » (dans Études Internationales, mars 2013).

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III. Incertitudes du collectif Collective Uncertainties

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The Shifting Epistemological Foundations of Cholera Control in Japan (1822-1900) Les fondations épistémologiques mouvantes du contrôle du choléra au Japon (1822-1900) 1822 から 1900年間日本に於けるコレラ抑制の変動する認識論的基礎

William Johnston

Introduction

1 Although generally not discussed in these terms, modern Japan’s first foreign occupation occurred during the nineteenth century. The initial invasion occurred in 1822, long before the arrival of Commodore Perry in 1853, not to mention General Mac Arthur’s army nearly a century later. While this first invasion did not result in a long- term occupation, its second invasion in 1858 most likely did, with calamitous consequences for the Japanese people.

2 This occupation is not thought of in these terms because the invader was an invisible intruder, Vibrio cholerae, the bacillus that causes cholera. More specifically, it was Vibrio cholerae of the serogroup O1, of what has become known as the classical (as opposed to the El Tor) biotype, although it is not clear whether it was of the Inaba or Ogawa serotype.1 While for some it might seem surprising to consider a bacillus as a historical actor with this level of agency, there is no denying that, in the words of Bruno Latour, it “does modify a state of affairs by making a difference.”2 The cholera bacillus made a difference both in people’s lives and in the practices and institutions of medicine and public health.3 Although exact statistics do not exist, especially for the 1822 epidemic or for the years between 1858 and 1876, according to the official figures, between 1877 and 1900, cholera killed over 530,000 persons. The disease also caused inestimable social and economic disruption.

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3 How people in Japan—physicians and laypersons alike—understood this invader reflects changing approaches to understanding both the natural and human worlds. Those changes were in part the result of increasing contact with Western ideas about cholera and its control. Yet it is also important to remember that even in Europe those ideas were often conflicting and undergoing rapid changes during the last half of the nineteenth century. The changing understandings of cholera in Japan were also in part the result of changing conceptions and infrastructures of public health in which the modern state took on a larger role in the health of the Japanese people as its leaders imagined necessary for the health of the state itself. Where the health of the people was physical and dealt with bodies one could see, the health of the state was conceptual and dealt with an imagined body, although one whose reality few questioned. Finally, and perhaps most importantly, understandings of cholera depended on how the Japanese saw themselves in reference to the rest of East Asia and the world. Cholera itself had a political significance that played out in these understandings, as contemporary descriptions of the disease show.

4 The goal of this essay is to trace how the dominant understandings of cholera changed during the nineteenth century, and how a confluence of multiple understandings of cholera facilitated the establishment of public health institutions aimed at controlling this disease. Only during the last decade of the nineteenth century did a single, bacteriological explanation of cholera’s etiology begin to dominate the discourses of medicine and public health in Japan, yet this did not prevent the creation of an integrated state apparatus for the control of the disease during the 1870s and 1880s. This was possible because in nineteenth century Japan, as in nineteenth century France as shown by Bruno Latour in The Pasteurization of France, there existed an infrastructure of hygiene that predated the rise of bacteriology as a foundation for the institutions of public health.4 In Japan, the idea of hygiene (eisei) was transplanted onto the idea of “nourishing life” (yōjō, also translated as “regimen”), which had developed a large and sophisticated body of literature by the end of the eighteenth century.5 In short, the rise of bacteriology was not necessary for the creation of state-directed cholera control measures in nineteenth century Japan, but rather was only one additional element in the contemporary epistemological transformation of cholera. The state apparatus emerged from a confluence of indigenous ideas about health and well being with Western ideas of hygiene to which bacteriology was a relative late comer.

5 An assumption at the foundation of this essay is that when nineteenth century Japanese documents refer to cholera, beginning in 1822 and continuing thereafter, it is the same disease that medicine today calls by the same name. When cholera first appeared in Japan in 1822 it displayed symptoms and a prognosis unlike anything previously known. Its name spawned a new Japanese word—korori— that punned on the Western term. The full name was mikka korori, or “three-day collapse,” that reflected the rapid progression of the disease from first symptoms to death; in a variant, the disease also was called mikka tonkoro, which meant the same thing.6 Unlike many other diseases such as syphilis and tuberculosis, cholera’s distinct signs and symptoms make it possible to trace the history of this malady from its initial pandemic in 1817 to contemporary times. We can, nonetheless, assume the existence of a gap between cholera as an ontological entity understood through biology, pathology, and related sciences today, and the epistemological frameworks of the past. Once we assume that Vibrio cholerae as we understand it today was essentially the same organism that first

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invaded Japan in 1822 and occupied it later in the nineteenth century, we can also assume that its behavior then was close to what it is now. This is, of course, an arbitrary assumption in that what modern medicine accepts as cholera’s ontological reality is based on later epistemological foundations: we don’t know for certain much about the bacillus that existed during the nineteenth century. This might change in the near future, as archaeologists have discovered a mass grave in Italy that contains bodies of what they believe to be cholera victims, and they are in the process of analyzing DNA samples for what they suspect is the cholera bacillus.7 Nevertheless, during the past twenty years we have learned much about Vibrio cholerae and the disease it causes, while the organism continues with its own development as determined by its biological properties and the ecologies in which it finds itself.

6 By accepting the fact that our knowledge of cholera continues to evolve, we can avoid the idea that bacteriology introduced the first “accurate” knowledge of this organism. Rather it is possible to measure the degree of overlap between pre-bacteriological thought and how we understand the disease today without assuming that the adoption of Western “scientific” thought was intrinsically superior to previous understandings of this disease. During most of the nineteenth century medical scientists in Europe, the United States, and Japan embraced conflicting understandings of cholera while competing for ascendency. The story that emerges hardly follows a linear progression. By no means is it the goal of this paper to show how earlier epistemologies inevitably developed into today’s scientific knowledge. It is, rather, to show how changing understandings of cholera manifested palimpsests that evidenced traces of earlier knowledge, while at the same time to demonstrate how the questions and problems of one period often disappeared into irrelevancy rather than being answered in the next. Epistemological change in the science of cholera occurred not simply due to the diligence of scientists but also due to the forces of politics, economics, and religion. It came about through what Latour called “translations, drifts, and diversions.”8 The following discussion examines some of the most significant of those translations, drifts, and diversions so that the forms and textures of the Japanese historical transformation that occurs with cholera’s occupation of the country become apparent.

A new disease : 1822

7 Perhaps the single greatest mystery in the history of cholera is why it initially spread around the world when it did. The first wave out of India arose in 1817. Before that, there were reports of a disease whose symptoms seem to be those of cholera as we know it today. Premodern Indian texts contain references to a violent enteric disease that suggest cholera. As far back as the time of Vasco da Gama (1460-1524), European travelers described a disease that might have been cholera. And in the eighteenth century, British seamen reported a disease with cholera-like symptoms.9 However if the disease we know today—and more specifically the Vibrio cholerae strain that causes it—existed before 1817 it is unclear why it did not spread beyond the Bay of Bengal before then. Technology does not seem to be the reason: travel to Asia did not suddenly become easier at this time, as steamships did not traverse ocean routes to India until the 1850s.10

8 One possibility is that a biological change in the cholera bacillus occurred at this time. Vibrio cholerae itself is a common bacillus that appears worldwide. However the form of

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the bacillus that causes cholera as we know it requires co‑infection with two separate viruses, known as bacteriophages, in order to become pathogenic. It is possible that new forms of bacteriophages or other genetic material changed the structure of Vibrio cholerae in a way that allowed it to travel more widely than before.11 In any event, from 1817, pathogenic Vibrio cholerae set out on what became a global colonization project. It came to reside in estuaries and other waterways from which it caused outbreaks of disease across the world. This was possible because the bacillus remains viable not only in the ecology of the human body but also in a range of creatures ranging from plankton to fish and birds. It did not, in other words, require constant transmission among humans in order to inhabit a local environment. In the last decades of the twentieth century cholera had become widely endemic, by which time the idea of cholera pandemics, which made sense during the nineteenth century, was no longer useful.12

9 When cholera did finally emerge beyond the Bay of Bengal from 1817, the first pandemic did not reach Europe. It spread across South and Southeast Asia, reaching Batavia by 1820. Contemporary Japanese sources note that Jan Cock Blomhoff (1779-1853), who became the Director (opperhoffd) of the Dutch mission on Dejima in Nagasaki harbor from 1817, gave the Japanese their first descriptions of cholera as it had struck Jakarta.13 In 1822 the disease reached Nagasaki and then proceeded to the Hiroshima area, the island of Shikoku, and as far as Osaka and Kyoto. It stayed primarily along the seacoast and rivers and was reported going east toward Edo (present-day Tokyo) but began to recede before arriving there. Between the eighth and tenth months of 1822 cholera killed several thousand but then disappeared from Japan for 36 years.14

10 Nevertheless, the disease clearly made its mark. Contemporary observers noted that it was similar to a disease known in Japan at the time as kakuran.15 As a disease category, kakuran (Chinese, huoluan) was based on Chinese medical thought that dated to ancient times.16 By the eighteenth century, the Chinese revival of ancient medical thought, and in particular of the Shōkanron (Ch. Shanghan lun) and its elaboration by Zhang Zhongjing had become highly influential among Japanese physicians.17 Kakuran was a prominent disease category for practitioners of this school, which remained influential in Japan into the 1860s.18 Although scholars have debated whether cholera as we know it today was introduced to China before it arrived there in 1820 during the first pandemic, it seems likely that kakuran was analogous to what people in the contemporary West called mordisheen, mort-de-chien, or cholera morbus.19 All of these had symptoms of diarrhea, nausea, fever, and debilitation and could cause death. Food poisoning was frequently the cause, which, as we know now, would have been common due to a lack of refrigeration and the use of night-soil as fertilizer. Nineteenth-century medical texts do associate kakuran with the contamination of food and drink, but also consider heat and cold and an individual’s personal physique to be key causes of this malady.20 In addition, it is important to keep in mind that disease categories at the time were often vague—just as they were in European and North American medicine—and diagnosis depended on a physician’s intellectual allegiances. At least until the 1870s, Japanese physicians whose practices were based primarily on Chinese ideas tended to diagnose kakuran whereas those who were influenced by European medicine tended to diagnose korera (or korori).21

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11 While, in historical perspective, this was cholera’s first incursion into Japan, at least one contemporary observer, Hirahira Yūteki, a physician to the lord of Aki domain in modern-day Hiroshima prefecture, believed it had appeared in the previous century.22 In 1842, Hirahira wrote a work called Korori ben (Treatise on cholera) in which he noted his observations from 1822: “I have observed many maladies, including influenza, mordisheen (kakuran), smallpox, infections, and they all were different from this disease. Although various treatments were attempted none were effective…. Commonly, this was called korori.”23

12 While in this way Hirahara asserted that this disease was unlike any he had seen himself, he also claimed that the disease had previously appeared in Japan. He wrote that 50 or 60 years earlier, which would have been in the 1780s or 1790s, people had seen this disease; he cited the Honzô kômoku (Chinese materia medica; Bencao gangmu in Chinese). There is no entry for korori in this work; there is one, however, for kakuran, which implies that Hirahara was equating korori with kakuran—something he does explicitly in a later passage of the Korori ben.24 Hirahara was, in effect, looking for ways to translate unusual phenomena into a language common to himself and his contemporaries. His struggle was self-conscious. He wrote: It is possible that biased views and deluded theories can arise. One should not be mistaken this way. The section of this work that contains the description of mordisheen (kakuran) specifies that it includes vomiting and diarrhea, and hence this name is used. This illness also includes the occurrence of fever, headache, lethargy, and chills, in addition to nausea and diarrhea. Together, these are called kakuran. Furthermore, the main section of this work calls for an examination of the pulse, and based [on the fact that both diseases show] similar symptoms, what we know as korori is thus kakuran. This [disease] is kakuran. Confucius says, “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot be carried on to success.” 25 If I have made these claims without properly keeping names in order, then I fear that [therapy and prevention] will not be successful.26

13 For Hirahara, the correct understanding of disease depended on the correct clinical understanding of its signs and symptoms. He looked for a familiar framework in order to grasp symptoms that were familiar yet unique. In addition to describing the symptoms of kakuran, he also included fever, the cessation of urination, cramps in the limbs, which also then became extremely cold, and delirium. Finally, he specified that there was no successful treatment for this disease, and presented a series of case histories in which only two out of eleven patients, whose ages ranged from 2 to 60, recovered.27

14 Other contemporary accounts of the 1822 epidemic described similar symptoms, adding cyanosis, sunken eyes, and abdominal pain. They also noted that death could occur on the first day of symptoms but often occurred on the second or third day.28 Most recommended treatments form this time included opium, a recommendation that continued throughout the century. Prevention was limited to moderation in food and drink—the foundations of yōjō discourse. 29 It is also significant that accounts of this early epidemic clearly depicted it as coming from abroad. For example one contemporary observer, a physician named Sasaki Chūsetsu, after describing a conversation with a Dutch visitor to Edo in which he learned that cholera had reached Batavia two years earlier, in 1820, then wrote, “A kind of pernicious essence (reiki) has spread between heaven and earth, and has reached our country.”30

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15 While this first incursion by the cholera bacillus was short, having lasted only two to three months, it left its mark on Japanese medical discourse and language. As previously noted, a common word for cholera, korori, was a play on both the Western term for the disease—transliterated as korera in Japanese—and on the rapid course it often took. Hirahira’s text, while otherwise assuming a scholarly tone, included two lines of doggerel that revealed popular perceptions of the disease. One read: Korori to kokete sora ibiki, which translates roughly as, “Tumbling down and falling over, pretending to snore.” Sora ibiki or “pretending to snore” possibly referred to the death rattle. The other read: Yomego no hirune mo korori to se, or “Like a new bride taking a nap, tumbling right over.” This is as much a comment on relations between brides and their mothers-in-law as on the disease, in that brides had so many responsibilities that they hardly slept at night and as a consequence could fall asleep almost instantly during the day. Another explanation for the term korori was that a person with the disease could fall over dead three days after getting it, resulting in the name mikka korori or “the three-day collapse.”31 From the time of this first epidemic, the word for cholera in Japanese was written with Chinese characters that on the one hand could be read phonetically as korori while often, if not always, reading them as korera through the use of furigana (phonetic pronunciation guides). Although most of Hirahira’s text focuses on symptoms, diagnosis, and treatment, he does note that the disease was widespread. He wrote: “It was common among travelers and at inns, and destroyed households, leaving them unguarded.”32 While it is clear that this first epidemic of cholera had a powerful impact, a sense that the disease imperiled the entire country does not seem to have occurred. That would change with the second cholera epidemic to reach Japan.

Cholera’s second wave, 1858

16 Japan’s first invasion by the cholera bacillus in 1822 was short, generally localized, and caused relatively few deaths. The second invasion came in 1858, persisted for months into 1859, was extended, widespread, and caused deaths that possibly numbered over a hundred-thousand.33 The American ship U.S.S. Mississippi, which docked in Nagasaki in the sixth month of 1858, had sailors with the disease who were the source of its introduction. From there, cholera spread east and reached Edo the following month. According to one count, over a quarter-million residents of the city died from cholera during the next two months.34 Even if these numbers were exaggerated the toll was enormous. By the end of the year cholera had spread throughout most of the main islands of Japan. Whereas the first cholera epidemic resulted in only a handful of texts about the disease, this second epidemic elicited a large number of works, most by and for medical specialists, but also some written for a general audience by authors of popular literature, both fictional and non-fictional. Both kinds of works receive attention in the following discussion.

17 By 1858, a great deal of medical discourse in Japan had become part of a larger discourse that tied it together with much of Europe and North America. Japanese physicians had begun to translate various Western medical texts from the 1770s. By 1853, when Americans used warships to persuade the Japanese government to allow foreign ships into several ports and not just into Nagasaki, many Japanese physicians were gaining a familiarity with various Western medical ideas.35 As a consequence,

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when this foreign disease once again entered the country, Japanese physicians reached to foreign texts to help understand and treat it.

18 One such approach was exemplified by the work of a Kyoto physician named Shingū Ryōkaku. He wrote that on the 24th day of the 8th month of 1858, his older brother came to him and said that based on the way the disease was spreading, cholera (korori byô) would soon be upon them but they lacked any effective treatment for it.36 His father told him that the disease had appeared in Japan over 30 years earlier, when it was called mikka korori (three-day collapse), but that because it had remained for only a short time it had been impossible to establish its cause or find a cure. He also said that although practitioners who used Chinese medical theories had described similar diseases, they were not clear regarding causes or treatments. As a consequence, Shingū and another physician, Ōmura Ten, decided to translate a Dutch text written by a German physician, Georg Friedrich Most (1794-1832), and make it available to other physicians as quickly as possible. According to the translators, Most had contracted cholera and written his work largely based on personal experience.37 They began their translation on the 25th day of the 8th month of 1858, and finished on the 2nd day of the 9th month.38

19 The justification for this translation project was premised more on faith in European medicine than on evidence of efficacy. Based on Western sources, several contemporary Japanese writers noted that cholera had first spread from the Indian subcontinent from 1817 and during the 1830s reached to Europe and North America for the first time.39 Hence Europeans had more experience with the disease than did the Japanese. In the face of a new epidemic, Shingū and his collaborator threw themselves into this project, as he later recounted: The two of us devoted our efforts to translating this work in the face of this rapidly spreading epidemic. We closely read the chapter on prevention and obtained various medicines, including calumba root. In this way we were able to create an alcoholic decoction [with red wine and calumba root] as a preventive medicine, which we and our families drank; we also gave it to our acquaintances… [We took] 50 drops three times daily, added to one cup of good sake before meals. The theory was that the calumba should prevent the rotting of bile and strengthen the stomach. Other [ingredients] were to strengthen the stomach. The wine and alcohol were to help expel the corrupted ki [jaki] in the body. Many people were helped in this way.40

20 Later in this same work, Shingū wrote that he had treated 42 cholera patients and had cured 33—a high success rate when considering that 50 to 60 percent of cholera patients often die if left untreated. His main treatment seems to have been a combination of salt water, sugar water, and rice water. It seems likely that this was based on treatments for kakuran, since there was no Western therapy in Japan at the time that used this combination. Because these are the basic ingredients for oral rehydration therapy, the main treatment for the disease today, there is good reason for this high recovery rate. Despite his success, this treatment did not become widespread and Shingū himself advocated Most’s recommended treatment: calumba root and red wine. Although calumba did not become a staple of the Japanese pharmacopeia at this time numerous texts on cholera published during subsequent decades did call for wine and sometimes brandy. All of these substances would have been extremely expensive and difficult to procure. Shingū also recommended opium to treat cholera. This also would have been expensive and difficult to acquire, yet perhaps easier to find than red wine was at the time. The emphasis on alcohol and opium as treatments, and at least

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for the former as a preventive measure, continued throughout the century even as explanations of cholera’s pathology and etiology changed considerably.

21 Shingū’s approach and analytical methods reflected current trends. Although he kept case records, he did not systematically compare treatment methods numerically. In addition, even when translating (from Dutch) a text by a German physician, he explained the efficacy of alcohol as a preventative based on the familiar notion of corrupted life force energy (ki); this parallels similar conceptual cross-overs that occurred in China around the same time.41 In this way, the importation of ideas occurred on the basis of existing conceptions of pathology and physiology.

Changing views of endemicity: 1877-1900

22 The Japanese experience with cholera points to the limits of the imaginary of pandemics as spreading worldwide. The first wave of cholera definitely fit in the first pandemic, which is usually dated from 1817 to 1824. The second and third pandemics, dated from 1827 to 1835 and from 1839 to 1856, did not reach Japan. Four of the subsequent cholera epidemics in Japan, in 1858, 1862, 1877, and 1879, did not occur during global pandemics: the fourth pandemic is dated from 1863 to 1875. On the other hand, subsequent Japanese epidemics during the 1880s and 1890s did occur during the fifth pandemic, which went from 1881 to 1896. In any event, from 1877 until 1924, cholera cases if not fatalities appear annually in government statistics, marking the beginning of endemic cholera that occasionally developed into domestic epidemics if not regional or global pandemics. Japan’s largest single epidemic, in 1879, caused over 100,000 deaths with a case fatality rate of 65 percent; this year also fell between the standard pandemic dates. Between 1877 and 1900, cholera deaths reached five figures on five separate occasions, with a total of over 360,000 deaths during those years (see Table 1). Indeed, cholera cases were reported every year between 1877 and 1924, and became rare only after 1930.42

Table 1. Cases, Deaths, and Case Fatality Rate, 1877-1900

Works on Cholera in NDL Cases Deaths Case fatality rate ( %) Digital Data Base

1876 0 0 - 0

1877 13,816 8,027 58 18

1878 902 275 30 0

1879 162,637 105,786 65 10

1880 1,580 618 39 24

1881 9,389 6,237 66 1

1882 51,631 33,784 65 9

1883 969 434 45 6

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1884 904 417 46 1

1885 13,824 9,348 68 0

1886 155,923 109,012 70 7

1887 1,228 655 53 12

1888 811 460 57 4

1889 751 431 57 1

1890 46,019 35,422 77 3

1891 11,142 7,767 70 2

1892 874 497 57 4

1893 633 364 58 16

1894 546 314 58 1

1895 55,144 40,241 73 8

1896 1,481 908 61 10

1897 894 488 55 0

1898 655 374 57 1

1899 829 2 0 0

1900 378 0 - 1

“NDL” is the Japanese National Diet Library

23 As one would expect, the epidemic of 1877 drew a great deal of attention from the medical community, as did subsequent major epidemics, with substantial numbers of monographs on cholera usually being printed in the year following a major outbreak (see Table 1). The National Diet Library lists two books published on cholera in 1871 and 18 in 1877, but none in the intervening years. Nor does it record any as having been published in 1878, but 10 were published in 1879 and 24 in 1880. The year 1893, when 16 works on cholera were printed, was an exception to this trend. However 12 of the books published that year were the Home Ministry Hygiene Bureau’s (Naimushō Eiseikyoku) accounts of the epidemics of 1877, 1879, 1882, 1885, 1886, and 1890. The Kumamoto prefectural government also published in 1893 a record of the epidemic of 1891. While all of these works include short historical depictions of cholera in Japan until that date, they focus on how the epidemic unfolded in each prefecture. The most detailed of all the reports is for the epidemic that occurred in 1879, which included descriptions of how people in each prefecture resisted the Hygiene Bureau’s cholera control measures. It is not clear why all of these works were published in 1893. The report for the epidemic of 1877, for example, is dated as having been written in November of that

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year.43 One possibility is that they were originally written for internal use by the Hygiene Bureau which later decided to make them public.

24 Of particular interest here are inconsistencies they contained from year to year in how observers understood cholera’s origins. In the report of the epidemic in 1877, Nagayo Sensai, who was the founding head of the Hygiene Bureau and remained in that position until 1892, wrote: In the past, when cholera has appeared and become epidemic in Japan, it was sufficient to say that in all cases it had arrived from Java or from China. However in specific locales there are now spontaneous cases of one or several cases of cholera or even small epidemics of cholera. In this respect it has become a kind of local disease [fūdobyō], and even today it has not completely disappeared although I believe that it will eventually be eliminated.44

25 National statistics for cholera morbidity and mortality were not compiled and published until the previous year, so it is somewhat puzzling that Nagayo would have made such a blanket statement. It is, moreover, telling that he considered cholera— which was still a relative newcomer—to be a localized, and in that sense endemic, disease described by the term fūdobyō. Nagayo shared a popular view of cholera described in Hata Ginkei’s Chimata no yume (Streetcorner dreams). This was a collection of essays for general readers on the cholera epidemic of 1858, which in at least one scenario described cholera as caused by demons specific to a particular locale, who could be scared away by using Buddhist amulets.45 Indeed, there was a great deal of popular belief that cholera, like other diseases such as smallpox, had local deities as their cause. In addition to the above work by Hata, Kanagaki Robun’s Ansei korori ryūkō ki provides examples of beliefs that deities caused cholera. 46 In other words Nagayo, while by no means associating himself with popular religious beliefs, was not particularly unusual in claiming that cholera had become a local disease.

26 Subsequent annual outbreaks confirmed endemicity although there was resistance to admitting it. The epidemic that started in March of 1879 and became the largest on record originated in Ehime Prefecture; it spread from there to Oita Prefecture and then across the rest of Japan. Seemingly reluctant to admit that the epidemic had domestic origins, authors of the Home Ministry’s report on that epidemic claimed that Chinese sailors had first brought cholera to Nagasaki but cited no evidence and no explanation as to how Chinese sailors in Nagasaki might have instigated an outbreak in Ehime.47 The epidemic that started in 1882 clearly originated in Kanagawa. Yet this was ambiguous, in that simply by citing Kanagawa—where the port of Yokohama and numerous foreigners were located—as the starting point might have been sufficient at the time to imply a foreign origin, although the authors of that year’s report make no such claim.48

27 On the other hand, the official report of the relatively minor epidemic of 1885 depicted all previous cholera outbreaks as having been brought to Nagasaki or Yokohama from other parts of Asia, that year from China.49 The narrative thread of that year’s cholera epidemic created an implied hierarchy between China and Japan. As the origin of the disease, China was placed in the position of an inferior nation, whereas Japan was described as a civilized, modern nation on the cutting edge of science. The Hygiene Bureau sent the bacteriologist Kitasato Shibasaburō to Nagasaki to confirm the presence of the “comma bacillus,” which had been confirmed in 1883 as the cause of cholera by Kitasato’s future mentor, Robert Koch.50 Nagayo’s contention eight years earlier that cholera had become endemic ran against this somewhat triumphalist

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narrative, and as a consequence was ignored, although Nagayo himself remained head of the Hygiene Bureau at this time.

28 Yet the following year’s epidemic, the second worst on record, put to rest the idea that outbreaks of cholera had to be of foreign origin. The epidemic was reported as having multiple sources, all domestic. In early January of 1886, cholera appeared in Osaka, without any reported links to foreign sources. At the time, Osaka was a city of canals from which people drew drinking and cooking water, at the same time dumping sewage into them.51 Later that January, cholera also struck fishermen in Tokushima Prefecture, starting a localized outbreak that lasted for approximately two months. And in March of that year, another localized outbreak appeared in Wakayama Prefecture, also lasting for several weeks. Cholera then spread throughout most of the country, with only distant parts of Kyushu and Hokkaido being spared with a small number of cases.

29 Although the epidemic of 1886 was the result of endemic cholera, this fact did not bring attention to the hundreds of deaths from the disease that occurred in “non epidemic” years or permanently change understandings of its epidemics as being primarily of foreign origin. In reality, by the 1860s, Japan had become entwined in a network of microbial transmission that ignored political boundaries in East Asia. Cholera had become regionally endemic and epidemics could have had either local or more distant origins. The next major epidemic, in 1890, did seem to have foreign origins, although the evidence is circumstantial.

30 In June of 1890, cholera struck the resident of a village in Nagasaki Prefecture who had helped unload a German ship that had just arrived from Hong Kong. Other dock workers from another village had previously died from a severe diarrhea, although they had been buried before it was confirmed as cholera. The official report of that year’s epidemic argued that the harbors and ports of Nagasaki were constantly unloading ships from China and India, and as a consequence were subject to cholera outbreaks.52 While this certainly was possible, it is telling of contemporary understandings regarding cholera and Japan’s relation to the disease that official government reports insisted on its foreign origins. It seems probable that as the Japanese adopted Western institutional forms and technologies more quickly than their neighbors in Korea and China, they became loath to see a disease associated with filth as endemic to their own country. Public health officials had reason to believe that their progress with public health measures implied that cholera epidemics had to be of foreign origin. The official report on the epidemic of 1890 discussed at length how cholera prevention had become the responsibility of the police, with local municipalities directly enforcing the central government’s laws on cholera prevention and disinfection. It went on to claim that despite some initial problems with the implementation of this system, the results went “beyond expectations.”53

31 This view might have predominated had the epidemic of 1895 not occurred. With over 50,000 reported cases and 40,000 deaths, that year’s epidemic was the third worst on record. Happening as it did in the midst of Japan’s first modern war, it also instigated significant reforms. Nagayo Sensai wrote that cholera was a threat to the state and that it had to be prevented from entering Japan from abroad, in particular via mail boats from the continent. He also demanded that people stop hiding cases and that they think of going to quarantine hospitals as a necessary sacrifice for the state, and by implication no different from that of soldiers who were sacrificing themselves at war.54 Perhaps in response to Nagayo’s call for more stringent measures, although he had left

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the Hygiene Bureau in 1891, the government instituted further reforms following this epidemic. Where previously the local police had been left in charge of prevention and disinfection measures, from 1895 the Tokyo Metropolitan Police Department (Keishichō) was put in charge of national cholera control with the establishment of the Office of Cholera Prevention (Korera Yobō Jimusho), which also was given responsibility for controlling dysentery and plague.55 One reason for this was the fact that military personnel coming from China had brought the disease into Japan via Hiroshima and Moji in Fukuoka. Another reason was the expectation that the strict leadership of the Tokyo Metropolitan Police Department could implement not only the Cholera Prevention and Disinfection Law but also the “Cleanliness Law” (Seiketsu Hō) and related measures, which required the regular cleaning of houses, separation of wells and latrines, and similar measures.56 In the long run, these changes seem to have been successful in that national cholera epidemics ceased after 1895. Only on two more occasions did reported cases of cholera exceed 10,000, when they reached 13,362 in 1902 and 10,371 in 1916.

32 To observers today, it might be surprising that the Japanese people had to be instructed and encouraged regarding cleanliness. Yet before this top-down enforcement of sanitary measures, it was primarily members of the samurai class and the economic elite who regularly cleaned their residences. The official reports on cholera note that people did not separate latrines and water sources and that in some parts of the country open cesspools were common. In this way, understandings of cholera that associated the disease with filth and making these understandings the basis for government policy did more than anything else both to control the disease and to change habits regarding personal and public hygiene. It is notable that unlike in Germany, as discussed below, the rise of bacteriological thought was not necessary as a justification for the central government’s intervention in local communities and individual households alike.

The bacteriological shift

33 Some readers probably have noted that bacteriology has been almost entirely absent from this discussion of changing epistemologies of cholera in Japan. In no small part this is because while important, it played a secondary role in how people other than medical and public health specialists understood the disease. As noted in the official record concerning the epidemic of 1885, Japanese health officials certainly were aware of Robert Koch’s having established the “comma bacillus” as the cause of cholera, although debates concerning its exact etiological role continued in Japan and Europe alike for another decade. However the discovery of the cholera bacillus in itself changed virtually nothing with regard to the prevention and control of the disease. It seemed to affirm the validity of disinfection measures using primarily carbolic acid, as well as calls for people to boil their water and avoid contaminated foods, measures that had been advocated from the 1870s.57 And knowledge of the cholera bacillus did nothing for therapy, as contemporary observers noted.58 Physicians continued to struggle in their attempts to find effective therapeutic measures and emphasized the use of opiates well into the twentieth century.

34 Discussions of the cholera’s etiology in the Japanese medical community followed lines of intellectual identity and allegiance. In response to the first two epidemics in 1822

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and 1858, that identity depended on whether one thought of disease in terms of Chinese or Western medicine. As growing numbers of Japanese medical students went to Europe—primarily Germany—in the nineteenth century, ideas of etiology depended more upon the views of one’s European teachers. With the emphasis on German schools, however, the bacteriological thought of Louis Pasteur or the hygienic ideas of John Snow received little attention in the Japanese medical world. For the most part, those who had studied with Robert Koch accepted his bacteriological theory and those who had studied with Max von Pettenkofer supported his multi-factorial theory of cholera’s etiology. There was little doubt to either that cholera was somehow transmitted from person to person, but the mode of transmission remained an object of debate until the last decade of the nineteenth century. Hence quarantine and disinfection, measures that had been implemented by the 1870s, remained the cornerstone of cholera control.

35 Ishiguro Tadanori, in his synthesis of several German texts on cholera that he published in 1871, supported Pettenkofer’s thesis that something in the feces of cholera patients transmitted the disease, while also asserting that it could be spread through the air.59 However it was during and following the epidemics of 1877 and 1879 that cholera became firmly associated with some kind of organism, which led to an emphasis on control through quarantine and disinfection. The numerous texts that advocate disinfection, however, do not generally theorize its efficacy. Following Pettenkofer and others, some writers speculated that a microscopic organism was responsible for the disease and by implication that disinfection neutralized those organisms; at least one work published an illustration, presumably drawn from an unnamed German text to which it refers, that showed microscopic “plants” thought to cause cholera.60

36 As a consequence, although the Japanese medical community was aware of Koch’s confirmation that the “comma bacillus” caused cholera, not all of its members saw the discovery as particularly momentous.61 As noted above, Kitasato Shibasaburō was sent to Nagasaki in 1885 to determine whether the bacillus caused the disease. He reaffirmed Koch’s bacteriological theory but doing so made no significant difference to prevention or therapy. During the rest of the 1880s and into the early 1890s, the primary debate among Japanese physicians regarding the etiology of cholera was between supporters of Koch’s theory that the bacillus alone caused the disease and supporters of Pettenkofer’s theory that emphasized soil and ground water as key elements in causing the disease.62 The difference between the two theories with regard to cholera control policies was significant. Koch’s focus on the bacillus called for an emphasis on disinfection, quarantine, and keeping human waste out of water supplies. Politically, Koch’s position called for government intervention to reach these goals. Pettenkofer’s position represented an extension of earlier miasmatist thought and called for a broad, social hygiene approach to the control of disease. He advocated minimal government intervention and emphasized the local control of poor sanitary conditions that had been associated with the outbreak of an epidemic, conditions based on a combination of meteorological, geological, and statistical analyses.63 Pettenkofer’s theories were eventually eclipsed after 1892, when a cholera epidemic devastated Hamburg, whose leaders had championed his ideas for controlling the disease. Nevertheless, some writers in Japan continued to question the idea that water-borne bacilli were the main cause of cholera as late as 1893, while others continued to support Pettenkofer’s theory the following year.64 After 1894, however, Pettenkofer’s ideas

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regarding cholera received little attention in the Japanese medical press. Rather it is telling that in 1895, we find Nagayo Sensai calling for municipal supervision of cholera prevention measures, focusing on quarantine hospitals and disinfection, the same measures that had provided the focus for cholera control for nearly two decades. However where Nagayo had declared that cholera was a local disease in 1877, in 1898 we find an anonymous writer in the leading public health journal, Dai Nihon Shiritsu Eisei Kai zasshi, asserting that it was the “opening” of Japan that made the country susceptible to the disease and that it always was and remained a foreign threat.65 Although in reality a relatively new microorganism had occupied the country during the last third of the century, as time went on, the Japanese increasingly understood it as something extrinsic.

37 In addition, it is important to note that despite the emphasis by historians of medicine in recent years on John Snow’s ideas concerning the role of water in the transmission of cholera, the Japanese medical press hardly mentioned Snow throughout the nineteenth century.66 Although the idea that water transmitted the disease persisted in Japanese understandings of cholera, until the very end of the century the means for dealing with impure water fell on the individual, through disinfection or boiling. It was not until the very end of the century that we find the literature on public health calling for the municipal control of water sources as the best way to prevent cholera, dysentery, and other water-borne diseases.67 Until then, ideas of hygiene based on individual behavior, even if it was forms of behavior that followed the direction of the central government, dominated understandings of cholera and its control. Thus, the rise of bacteriology did not radically transform Japanese control policies regarding cholera. Rather it reinforced claims that the involvement of the central government was necessary to enforce behavioral changes in historically unprecedented ways while often emphasizing the individual in ways that did parallel the ideas of yōjō.

Conclusion

38 The ways in which Japanese physicians and health officials saw and understood cholera as it swept across the country in epidemic waves and eventually became endemic reflect the broad changes that the country experienced during the nineteenth century. One set of changes marked Japan’s increasing integration in a global network of pathogenic exchange, and can be divided into three periods: the first included the first two epidemics of 1822 and 1858; the second reached from the late 1870s to approximately 1890; the third spanned last decade of the century.

39 Foreign contact first brought the disease well before the “opening” of Japan in 1853. The second epidemic in 1858 clearly entered via Nagasaki, and as a consequence could have happened the way it did even before the treaty ports other than Nagasaki were made accessible to foreigners. Yet as the collections of popular essays on cholera by Hata Ginkei and Kanagaki Robun reveal, at least to many people in Japan cholera was not yet understood so much as a foreign threat as a result of demonic or karmic influences; that is, an existential threat whose origins were less important than the challenge of survival. This perspective contrasts starkly with the Kyoto physician Shingū Ryōkaku’s work, which is based largely on a text on cholera by the German physician Georg Friedrich Most and describes the disease as originating in India and coming to Japan.

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40 Whether there were any significant cholera epidemics during the 1860s is debated. Contemporary Western observers did report the disease in 1862, but Yamamoto Shun’ichi, author of the most comprehensive history of cholera in Japan, questions whether the epidemic that struck was actually cholera.68 In any event, by the time the next major epidemic struck in 1877, the disease had become so pervasive that Nagayo Sensai considered it to have become a local disease (fūdobyō), in other words endemic to certain parts of the country. This was, in all likelihood, an accurate observation. Our knowledge of Vibrio cholerae as it stands today strongly suggests that the organism that causes cholera could have become acclimated to Japanese waterways and estuaries by this time. And the statistical record, which shows that there were at least hundreds and often thousands of cases of the disease every year between 1877 and 1900, also strongly suggests that cholera had indeed become endemic in Japan—that in effect Vibrio cholerae had occupied the country—during the last third of the nineteenth century. Nevertheless, understandings of cholera during that time, while becoming increasingly influenced by German debates over etiology, claimed the opposite and described the disease as a foreign intruder. Most likely this is the result of many in Japan seeing their country as leading Asia’s move toward modernization, which was associated with health and hygiene; cholera, on the other hand, had obvious associations with filth, debilitation, and death. There was, in short, a narrative based on ideas of civilization that depicted other Asian countries, and in particular China, as inferior that created the structure for late nineteenth century narratives regarding cholera in Japan. Japanese accounts of the disease tended to describe cholera as coming from China, and with the Sino-Japanese War of 1894-1895, China also became the great obstacle to Japan’s paternalistic and imperialistic efforts to facilitate the modernization of continental Asia and of Korea in particular.

41 What we see in the history of cholera in nineteenth century Japan is a case of disease associated with identity, and the epistemological framework for the disease was transformed, not just in the sense of its laboratory understandings but also in the sense of where the disease fit in a new cultural and political order. These understandings, more than those of emerging laboratory science and bacteriology, were the ones that dominated the public health discourse of the day. The historical process that they represent is a shift, a translation of a cluster of concepts that constitute understandings of cholera from ones that shifted individual responsibility for the disease from the ideas of yōjō, karma, and demonic spirits to the ideas of disinfection, isolation, and sanitation. The process did require growing state intervention, but even this required local cooperation and support. The drift that occurred was not simply a top-down process. Yet when the epistemology of the disease is considered in this wider context, it becomes clear that the way in which ontological shifts based on bacteriology and laboratory science more broadly played only a supporting role in this historical process. Historical continuity remains, even as the ontology of the disease is unstable. While this case is itself relatively minor when considered on a world stage, when one considers that all epidemics are local events, it has lessons that can be useful when trying to understand how they occurred in other localities.

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APPENDIXES

Glossary eisei 衛生 fūdobyō 風土病 furigana 振り仮名 (often written phonetically: ふりがな) Honzō kômoku 本草綱目 jaki 邪気 kakuran 霍亂 ki 気 korera often this was written using katakana: コレラ. Chinese characters used were the same as those for korori; see below. korori often this was written using katakana: コロリ; a number of Chinese characters were used phonetically for korori, including 虎狼痢,虎烈剌, 虎列剌,古呂利,古路里,国漉 栗,箇労痢. Often these would be assigned the phonetic reading korera. Korori ben 国漉栗辨 Korori to kokete sora ibiki コロリトコケテソライビキ (original in katakana). Korera Yobō Jimusho 虎列剌予防事務所 mikka korori 三日コロリ (While this was often written using the phonetic katakana, korori could also be written using any of the Chinese characters for korori that are noted above) mikka tonkoro 三日トンコロ reiki 厲気 Seiketsu Hō 清潔法 Shōkanron 傷寒論 yōjō 養生 Yomego no hirune mo korori to se ヨメゴノヒルネモコロリトセ (original in katakana). Zhang Zhongjing 張仲景

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NOTES

1. Colwell 1996: 2025-2031; Colwell 2004: 285-289. 2. Latour 2005: 71; see also Sayes 2013: 1-16. 3. Chemouilli 2004a; Chemouilli 2004b; Chemouilli 2004c. 4. Latour 1988: 16-26. 5. Takizawa 2011: 7-12; Andoh 2003; Chemouilli 2004c: 181-183. 6. Matsumoto 1980: 15. 7. Gibbons 2013: 1310. 8. Latour 1988: 11. 9. Colwell 1996: 2025. 10. MacPherson 1998: 492-494. 11. Faruque and Mekalanos 2012: 1-10. 12. Johnston 2012: 35. 13. Bunsei jingo aki tenkō byō koreri morubusu keiken n. d.: n. p; Yamamoto 1982: 3-5. 14. Matsuura 1859: n. p. 15. Matsuura 1859: n. p.; Hirahara 1842: n. p. 16. MacPherson 1998: 496-497. 17. Elman 2008: 108. 18. Odai 1864. 19. MacPherson 1998: 495-503. 20. Odai 1864: 8a, 9b-10a; Matsuura 1859: n. p. 21. Matsuura 1859; Odai 1864; Shingū 1858. 22. Hirahara 1842: n. p. 23. Hirahara 1842: n. p. 24. Taki 1918: 173-174. 25. Translation by Legge 1971: 263-264. 26. Hirahara 1842. 27. Hirahara 1842: n. p. 28. Bunsei jingo aki tenkō byō koreri morubusu keiken n. d.: n. p.; Matsuura 1859: n. p. 29. Bunsei jingo aki tenkō byō koreri morubusu keiken n. d.: n. p. 30. Sasaki n. d.: n.p. 31. Nakajima 1982: 46. 32. Hirahara 1842: n.p. 33. Yamamoto 1982: 8-25; Gramlich-Oka 2009: 32-73. 34. Yamamoto 1982: 19-23. 35. Fujikawa 1972: 498-513. 36. Shingū 1859: n. p. 37. Shingū 1858, vol. 1: 41. 38. Shingū 1858, vol. 1: foreword 1-2. 39. Umetani 1858: 3; Shingū 1858: vol. 1, foreword 1; Umasugi 1859: n. p. 40. Shingū 1859: n. p. 41. Andrews 1997: 122-129. 42. “Patients and Deaths of Infectious Diseases and Food Poisoning (1876-1899).” 43. Naimushō Eiseikyoku 1893 [1877]: 5. 44. Naimushō Eiseikyoku 1893 [1877]: 4. 45. Hata 1858: n. p. 46. Kanagaki 1858: 19b-20a; 24a. 47. Naimushō Eiseikyoku 1893 [1879]: 1. 48. Naimushō Eiseikyoku 1893 [1882]: 1.

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49. Naimushō Eiseikyoku 1893 [1882]: 3, 5. 50. Naimushō Eiseikyoku 1893 [1882]: 4. 51. Naimushō Eiseikyoku 1893 [1886]: foreword, p. 2, main text, p. 1. 52. Naimushō Eiseikyoku 1893 [1890]: 1-2. 53. Naimushō Eiseikyoku 1893 [1886]: foreword, p. 3. 54. Nagayo Sensai, Dai Nippon Shiritsu Eisei Kai zasshi: 646, 653-654. 55. Keishichō 1896: 1, 3. 56. Keishichō 1896: 1. 57. Nomura 1877: 4; Uratani 1877: 2. 58. Maeshima 1886: 850. 59. Ishiguro 1871: 5-6. 60. Itō 1879: n. p. 61. “Doitsu koku korera byō kenkyū iin no hōkoku” 1884: 773-774. 62. Tsuboi 1893: 78-80. 63. Evans 1987: 269-271, 494-496. 64. Yasuhara 1893: 254, 271; Watanabe 1894: 46-56. 65. “Densenbyō no shinro” 1898: 373-376. 66. Vinten-Johansen et al. 2003; Johnson 2006; Hempel 2007. 67. Noda 1899: 425-449. 68. Simmons 1880: 4; Yamamoto 1982: 26; New York Times 1862: 2.

ABSTRACTS

By focusing on primary sources from 19th-century Japan, this essay examines how the Japanese understood cholera at that time. Members of the Japanese medical community utilized both Chinese-based theories and European medical texts until the 1870s, when Western ideas dominated the discourse concerning cholera. However the dominant understandings of the disease shifted from seeing it as having become endemic during the 1870s to almost invariably being a foreign intruder by the 1890s. These understandings were based not on statistical or other scientific evidence but rather on cultural and political associations with cholera as a disease of filth.

Cet article, qui s’appuie sur des sources japonaises du XIXe siècle, explore les manières dont le choléra est alors compris au Japon. Les membres de la communauté médicale japonaise utilisent les théories médicales chinoises et européennes jusqu’à ce que ces dernières, à partir des années 1870, dominent le discours sur le choléra. Néanmoins la maladie, d’abord perçue comme un mal endémique dans les années 1870, est par la suite assimilée à un envahisseur étranger. Les représentations du choléra ne reposent alors ni sur des statistiques ni sur aucune preuve scientifique mais sur l’association, culturelle et politique, du choléra à une maladie de l’immonde.

当論文は、１９世紀の多様な一次資料をもとに、日本で当時コレラが如何に理解されてい たかを検討します。日本の医療関係者は、西洋のコレラに対する理論が主導権を握ること になる1870年頃まで、長らく漢方に基づく医学論とヨーロッパの医学テキスト両方を使用し て来ていました。それにもかかわらず、細菌学は主役を務められない脇役でしかないとい う前近代から近代にかけてのコレラ抑制に関する概念を翻訳した結果が、予防対策が最も

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重要であるという見解でした。さらに、1870年代頃までは、地方病（endemic)として見られ ていたのが、1890年頃には、国外から潜入したもとと理解するのが主流見解となる変化が起 きていました。そうした動きは、統計学的もしくは科学的物証から引き出された結果では なく、コレラが文化と政治に関連した結果でした。

AUTHOR

WILLIAM JOHNSTON

WILLIAM JOHNSTON received his PhD in History and East Asian Languages from Harvard. He is professor of history, East Asian Studies, and Science in Society at Wesleyan University, and the author of The Modern Epidemic: A History of Tuberculosis in Japan (1995) and numerous articles on the history of medicine and disease in Japan. WILLIAM JOHNSTON a obtenu sa thèse de doctorat en histoire et langues d’Asie orientale à l’Université de Harvard. Il est actuellement professeur au sein du département Histoire, Études Asie orientale, Science en Société de l’Université de Wesleyan. Il est l’auteur de The Modern Epidemic : A History of Tuberculosis in Japan (1995) ainsi que de nombreux articles portant sur l’histoire de la médecine et des maladies au Japon.

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Epidemic Cerebrospinal Meningitis during the Cultural Revolution L’épidémie de méningite cérébro-spinale pendant la Révolution culturelle 文革時期流行性腦脊髓 膜炎 大流行原因初探

Ka wai Fan

I would like to thank my three students Shum Wai, Ho Hinchi and Cheung Tinghei. We discussed this topic in July 2012. They inspired me to investigate this topic further. I have received a great deal of help from Prof. Lai Honkei of Sun Yat-Sen University in collecting research materials.

Introduction

1 Following the foundation of the People’s Republic of China (PRC), a program of public health reform was launched by the Communist Party of China (CPC) to shape the structure of the health care system. Four key principles were to guide the implementation of this system: the health care system should serve the workers, peasants, and soldiers; disease prevention should be prioritized over curative programs; Chinese medicine should be combined with Western medicine; and health promoting work should be carried out through mass movements. These principles underpinned the central values of public health care during the early years of the PRC, where disease prevention was thus given high priority.2

2 At first, the disease prevention policies were directed at smallpox, plague and cholera. However, following the start of the Korean War in 1952, the CPC Central Committee suspected that the United States was engaged in biological warfare.3 This prompted the CPC to start the Patriotic Health Campaigns (Aiguo weisheng): first providing information on health threats caused by disease-spreading insects that, in this context of suspicions of biological warfare, should be systematically destroyed. Similar campaigns were later launched for the prevention of other diseases. In 1956, for instance, Chairman Mao launched the anti-schistosomiasis campaign in the southern , with the slogan “aiguo weisheng.” The aim was to improve

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agriculture and water conservation, in order to enhance agricultural production and to eliminate schistosomiasis, thanks to mass mobilization.4

3 The Patriotic Health Campaigns, which made wide use of propaganda posters and pamphlets, were seen as effective means for implementing hygiene and disease prevention measures through mass mobilization. Above all, these campaigns showcased the consistent political approach adopted by the CPC in mobilizing the masses to attain the goals of central government.5

4 While the CPC was engaged in programs for the elimination of a number of diseases, its policies however encouraged the spread of others. During 1966 and 1967, after the Cultural Revolution had been launched and nationwide gatherings of students and Red Guards (Hong wei bing) were encouraged, an outbreak of cerebrospinal meningitis spread throughout the country, causing over 160,000 deaths.6 This outbreak did not reach high visibility, due to the successes that the CPC achieved in controlling smallpox, cholera, plague, tuberculosis, and malaria.7 And this particular outbreak of cerebrospinal meningitis has generally been neglected by historians in their worldwide history of the disease.8

5 Drawing on provincial archives, health gazetteers (weishengzhi) and local gazetteers (difangzhi) published in various provinces and counties during 1980-2000, as well as on notices, documents and handbooks distributed for preventing cerebrospinal meningitis in the 1960s, this article traces the course of the 1966-1967 cerebrospinal meningitis epidemic, and sheds light on the factors that led to this acute and nationwide epidemic.

Epidemic cerebrospinal meningitis in Beijing and nationwide

6 Epidemic cerebrospinal meningitis, caused by meningococcus Neisseria meningitidis serogroup A in China, is a bacterial form of meningitis, caused by the inflammation of the protective membranes covering the brain and the spinal cord. The bacterium spreads through contact with saliva from an infected, and possibly asymptomatic, person. Typically transmission occurs through coughing, sneezing, kissing or sharing drinking vessels, and the like. Epidemic cerebrospinal meningitis has a high mortality rate.9

7 As modern epidemiological studies have shown, several conditions usually contribute to the outbreak of an epidemic of cerebrospinal meningitis. First, because the disease infects tissues in patients’ and carriers’ throats, speaking, coughing, or sneezing can spread the virus through the air, resulting in a dramatic increase in the number of people infected in a short period of time. The likelihood of transmission is particularly high in non-ventilated environments. Second, climatic factors play an important role in the seasonal upsurge of meningococcal diseases. In China, the disease is extremely common in winter and early spring. Third, meningococcal diseases attain epidemic levels in places such as college campuses and barracks during mobilizations, where many people are living together for the first time. Fourth, travelling facilitates the circulation of the disease inside a country, or from country to country. In particular, since gatherings of susceptible people represent an important risk factor for outbreaks, large population movements play a major role in the spread of infection and diseases. Fifth, poor living conditions and overcrowded housing are linked with a higher

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incidence of meningococcal diseases. Sixth, young adults, children, the elderly, and peasants are particularly vulnerable to meningococcal disease. Finally, people in some remote regions may lack immunity to the disease; thus, when the disease invades that area, an epidemic is highly probable.10

8 The cerebrospinal meningitis epidemic cycle is 10 years in China. The disease was prevalent in China in 1957, 1967 and 1977.11 From autumn 1966 to spring 1967, the disease began to spread, and became epidemic in every major city. Afterward, it rapidly spread to medium-sized and smaller cities, as well as remote and border areas. The incidence rate in 1967 was 403/100,000 people, that is four times higher than the incidence rate in 1975, which was the highest rate since records began.12 From 1966 to 1967, the disease affected most provinces, and started to decline in 1968.13

Figure 1. Incidence of cerebrospinal meningitis in 1966 and 1967

Province Case (year) Incidence rate (per 100,000)

Anhui 254,961 (1967) 740.6 (1967)

51.59 (1966) Fujian 92,686 (1967) 502.12 (1967)

Gansu 7,978 (1967) 55.48 (1967)

5,810 (1966) 13.47 (1966) Guangdong 312,658 (1967) 705.04 (1967) 54,930 (1968) 120.6 (1968)

123,864 (1967) 482.49 (1967) Guangxi 43,820 (1968) 167 (1968)

Hainan 4,452 (1967) 115.6 (1967)

153.85 (1966) Hebei 101,838 (1967) 274.26 (1967)

Heilongjiang 38,900 (1967) 174.34 (1967)

244.5 (1966) Henan 356,082 (1967) 646.6 (1967)

Hubei 421,065 (1967)

16.21 (1966) 164,902 (1966) 400 (1967)

Jiangsu 170,166 (1967)

Jiangxi 265,000 (1967) 1140.6 (1967)

Jilin 7,289 (1966) 161.21 (1967)

Liaoning 51,931 (1967) 177.97 (1967)

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Ningxia 3,654 (1967) 376 (1967)

Qinghai 843 (1967)

78.50 (1966) 39,754 (1966) 177.16 (1967)

120.71 (1966) Shandong 336,666 (1966) 564.12 (1967) 187.97 (1968)

Shanxi 26,616 (1967) 136.71 (1967)

Sichuan 122,155 (1967) 163.29 (1967)

Xinjiang 7,090 (1967) 82.932 (1967)

Sources14: Anhuishengzhi Weishengzhi 1996: 298; Fujiansheng weisheng fangyi zhan yewu ke 1975: 37-42; Gansushengzhi Weishengzhi 1995: 127; Guangdongshengzhi Weishengzhi 2003: 173; Guangxitongzhi Yiliaoweishengzhi 1999: 133; Hainanshengzhi Weishengzhi 2001: 112; Hebeisheng weisheng fangyi zhan 1975: 50-62; Heilongjiangshengzhi Weishengzhi 1988: 120; Henanshengzhi Weishengzhi 1991: 212; Deng 2006: 621; Hunansheng weisheng fangyi zhan: 63-75; Jiangsushengzhi Weishengzhi 2003: 296. Deng 2006: 621; Jiangxisheng Weishengzhi 1997: 177; Jilinshengzhi Weishengzhi 1992: 36; Liaoningshengzhi Weishengzhi 1999: 76; Deng 2006: 621; Shaanxishengzhi Weishengzhi 1996: 185; Shandongsheng weishengzhi 1992: 365; Shanxisheng shizhi yanjiuyua 1997: 455; Sichuansheng zhi yiyao weishengzhi 1995: 142-143; Xinjiang tongzhi weishengzhi 1996: 130.

Picture 1

This picture shows that the number of epidemic cerebrospinal meningitis infected patients (xxx) was not disclosed. “Quansheng fangzhi liuxingxing naojisuimoyan gongzuo zongjie” 1967: 26. © Fan Ka wai.

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Picture 2

The map for Great Networking at Chongqing city. © Fan Ka wai.

9 Figures available for 1966, 1967, and 1968 (Fig. 1) clearly show that the epidemic peaked from 1966 to 1967 and declined afterward. However, Figure 2 indicates that the epidemic’s spread in Beijing differed from the provinces.

Figure 2. The data of cerebrospinal meningitis in beijing from 1966 to 1968

Year Infected people Incidence (per 100,000) Deaths Death rate

1966 22061 279.61 873 11.06

1967 10301 130.87 335 4.26

1968 2013 25.21 90 1.13

Source: Beijingzhi weishengzhi 2003: 171.

10 As indicated by the statistics, in Beijing the epidemic reached its peak in 1966 and declined in 1967, while in the provinces, the epidemic reached its peak in 1967. To understand why the disease spread so widely and quickly in the provinces, we need to look more closely at the social and political events of the Cultural Revolution.

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The Great Networking Movement within the Cultural Revolution

11 The Cultural Revolution started in 1966 with the publication of a number of Central Documents by the CPC. In one of these documents, the ‘May 16 Notification,’ Chairman Mao Zedong called upon students, who would come to play a vital role in contemporary Chinese history, to actively promote his reforms. Students gathered from all over China to form the Red Guards (Hong wei bing)15, and initiated a campaign to eradicate the ‘Four Olds’ (Si Jiu: Old Customs, Old Culture, Old Habits, and Old Ideas). This mass reform movement soon got out of control and led to a series of tragedies.16

12 Before September 5, 1966, every university in Beijing had put up posters advertising the Cultural Revolution. From this date, the CPC Central Committee requested that China’s university and secondary school representatives go to Beijing to observe the Cultural Revolution. Over ten thousand students and teachers were mobilized in a nationwide movement. Nationwide, Red Guards left their homes to go to Beijing and other sacred places of the Revolution to exchange their revolutionary experience, and spread the flame of revolution all over the country, in a mass movement known as the ‘Great Networking’ or ‘National Great Networking’ (Dachuanlian or Quanguodachuanlian). 17

13 Most of the Red Guards from outside the capital set Beijing as their final destination in order to meet and pay homage to Chairman Mao, and share their revolutionary fervor and experience.18 The Red Guards who were based in Beijing set out for various key sites, assembling especially in the sacred places of the communist revolution, such as the Jinggang Mountains, Yan’an, Dazhai, Zunyi, Shaoshan19 and Guangzhou (the biggest city in the south). It was a way of rekindling in the present the revolutionary spirit of the past.20 A proclamation of December 1 mentioned that Beijing, Shaoshan, Jinggang Mountains (visited by 900,000 Red Guards during the Networking Movement)21, Zunyi, and Yan’an were overcrowded with revolutionary teachers and students.22

14 Schooling was suspended nationwide, and the Great Networking stretched from North to South and from West to East.23 This movement led to chaos in China, paralyzing railways and crowding dwellings. As Deng Tietao and MacFarquhar Roderick highlighted, this mass mobilization also triggered a cerebrospinal meningitis epidemic across the country. According to MacFarquhar Roderick, before the autumn of 1966, outbreaks of epidemic cerebral-spinal meningitis were rare in China, and highly localized, in large part because of a low degree of popular mobility. The sudden mobilization of millions of people from every corner of the country in extremely cramped and unsanitary conditions put an end to this situation and paved the way for a massive epidemic. This contribution examines the ways this epidemic spread all over the country and how the authorities, sharing contradicting views, and belonging to different factions within the CPC, dealt with this epidemic.24

15 The political agenda of this movement was, in fact, inextricably linked with the spread of the disease. On August 8, 1966, Chairman Mao greeted the national representatives of the Red Guards for the first time at Tiananmen Square, in Beijing. From August to November 1966, 1.1 million students flocked to Beijing to worship Chairman Mao.25 However, Chairman Mao was not satisfied and believed that Beijing could receive up to three million Red Guards.26 To reach this goal, the central and local governments

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provided free transportation, food, accommodation, and medical services to the Red Guards, who also received support from their schools and local units in travelling to Beijing.27 The central government and State Council originally allowed students and representatives of the Red Guards to stay in Beijing for just four days. However, some newcomers considered this as an opportunity to see Chairman Mao in person. As a result, Beijing was even more crowded than usual as hundreds of thousands of students waited for a meeting with Mao. During their stay in Beijing, students relied on local schools for accommodation, sleeping on floors and sharing poor living conditions, which favored the spread of the disease.28 Meanwhile, since winter had arrived, cold weather provided an environment that further encouraged the virus and facilitated the spread of the disease. During this mobilization, there were 22,061 cases of meningitis reported in Beijing in the second half of 1966, with an incidence rate of 279.61/100,000, and a death rate of 11.06 (873 deaths). That year, the epidemic mostly affected Beijing. Although the CPC Central Committee was aware of the problem, it did not devise strategies to counter the situation.29 With ten thousand provincial students already ill in Beijing at that time, the Central Committee’s response was not providing them with treatment, but encouraging the sufferers to go home.30 Without adequate preventive measures, the epidemic spread from Beijing to every corner of the country, in the following months.

16 However, Beijing was not the only place the students gathered. Guangzhou, the biggest metropolis and transportation hub in the south, which had received over 1.6 million Red Guards by the end of 1966, was also a popular place for students to visit in order to exchange their revolutionary experience.31 Likewise, Red Guards from all over the country travelled by rail to Hunan province, home to many important cities and symbolic places such as Shaoshan, Mao’s birthplace. By November 1966, the disease had reached a number of cities and counties in Hunan. It started to spread from the highway connecting Changsha and Shaoshan, which concentrated the largest population mobilization. The disease not only spread to Zhuzhou, Hengyang, Yueyang, Chenzhou, but also to the cities on the railway, and villages on both sides of the railway and highway. By February 1967, the disease had become epidemic in Hunan and Guangdong provinces.32 In Guangdong province, the first cases of the disease were discovered in Xinhui, , and Liannan Yaozu Zizhi counties in 1967. The disease quickly spread throughout the People’s Communes Renmin gongshe, the basic rural administrative organization at village level in China from 1958 to 1983. Five students in Zhoubei and two in Guandu of were infected and died of the disease during the Great Networking Movement.33

17 At the end of 1966, the national Great Networking Movement unexpectedly moved in two new directions. Firstly, the movement which had primarily been reserved to students was joined by workers. Secondly, the movement, which had originally only focused on cities and revolutionary shrines, was extended to villages. Actually, on September 14, 1966, the CPC Central Committee had prohibited students and Red Guards from Beijing and other regions from entering villages below county level. Moreover, officials and village students below county level were not allowed to participate in the Great Networking Movement.34 However, on December 15, 1966, the CPC Central Committee ordered that the Cultural Revolution should be promoted in villages, as well, and that Red Guards should be formed there. Revolutionary students were now permitted to enter villages.35 This political change facilitated the transmission of the disease from cities to villages. Figure 3, drawn from health

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gazetteers from many counties in Guangdong province, shows that the disease not only appeared in Guangzhou city, but was also widespread in villages all over Guangdong province.36

18 With this change of policy, from winter 1966 to spring 1967, the disease became prevalent in all the major cities, and also reached remote districts, small towns, villages, the People’s Communes, and brigades37 along the railways and highways.

19 Transporting huge numbers of Red Guards all over China overwhelmed the railway system, and seriously affected the transportation of ordinary resources.38 Premier Zhou Enlai was deeply concerned that the Great Networking Movement which had paralyzed traffic across China, interrupting the supply of important goods and materials, would cause delays in reaching the objectives of the third five-year plan (1966-1970). To solve this problem, the central government took another decision that would later impact on the spread of the epidemic: while it did not stop the Great Networking Movement, it advised Red Guards and students to continue the movement on foot; central and local governments would no longer supply free transportation. On October 3, 1966, the People’s Daily (Renmin ribao) published a headline, “The Red Guards do not fear a long march,”39 to inspire the Red Guards to share their revolutionary experience through walking. This measure, which was intended to improve the economy of the country, and to avoid congestion in major hub cities such as Chongqing (picture 2), Guangzhou, and Changsha, indirectly facilitated the spread of the epidemic into villages and remote areas of the country that had been left untouched by the disease because they were too far from railways. It notably provided further opportunities for Red Guards to share their revolutionary experience in small towns and villages, and to communicate with peasants in more remote areas, who typically lacked immunity to meningitis, and thus were more easily infected.40

20 Knowledge about methods of prevention and a cure for cerebrospinal meningitis was however available in the medical community in China at that time. In 1961, a book, Prevention and Treatment of Epidemic Cerebrospinal Meningitis, was published by Dr. Wang Qihuang, from Shanghai Ruijin Hospital’s Department of Infectious Diseases. This book described how to prevent and cure the disease in 1950s China. It thoroughly reported six key facts relating to cerebrospinal meningitis: first, the disease usually occurred during the winter and spring seasons; second, patients were usually children; third, bacteria carriers were the source of the disease; fourth, it was necessary to keep indoor air pure and fresh; fifth, people needed to wear masks when they went to public assemblies or places of entertainment because these places were usually crowded, with turbid air; sixth, people should adopt indoor air sterilization when they were staying at epidemic-affected areas, or places with a high bacteria carrier rate. In terms of treatment, some effective methods for curing the disease were known and available, such as multiple sulfa drugs and antibiotics, and even some treatments using Chinese medicine. The book also pointed out that the Chinese New Year period was a period when this disease could spread widely and easily, as, before and after the Chinese New Year, people used to gather at places of entertainment, took public transport and visited shops.41 Dr. Wang’s book finally stated that when measures had been vigorously enforced by the CPC, the death toll from cerebrospinal meningitis had greatly reduced, and the incidence of the disease also apparently had declined in the 1950s.42 In the 1960s, the medical community in China had thus the proper skills and knowledge to have the disease under control.

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21 Given the resources available at the time, putting an end to the Great Networking Movement when the disease had appeared in Beijing, in 1966, would have been the most effective way to halt the spread of the disease. However, several political factors, including Mao’s utopist ideal of mass mobilizations, outbursts of enthusiasm by students and political struggles among different CPC factions hindered such a resolution. In addition, no one dared to openly blame the movement and its actors through of the fear of being accused of counter-revolutionary crime, publicly criticized and violently beaten. During this period (throughout the country) a significant number of people were beaten to death.43 In 1966, Chairman Mao’s movement could not be easily stopped because Mao’s utopist ideology was stronger than the Ministry of Health. While Premier Zhou ordered that students and Red Guards should not use railways in late 1966, because the transportation system was severely interrupted by the movement, it was impossible to stop the trend immediately. In some cases, students ignored the order, and continued to travel in trains.

22 In November 1966, as the traffic congestion situation worsened, the CPC Central Committee decided to temporarily halt the Great Networking Movement, and ordered students to participate in the revolutionary movement in their respective hometowns until the next spring when the movement would start again.44 The central committee of the CPC stopped calling upon students to gather at Beijing and the sacred places of revolution. Instead, it encouraged students to congregate with their neighbors and launch the revolution at home. It provided free tickets and accommodation to leave Beijing and return home, and re-opened schools.

Final decision on the termination of the Great Networking Movement

23 By early 1967 the epidemic had spread throughout China, which made it very difficult to control. Coming under pressure from local authorities, the CPC Central Committee and State Council addressed the epidemic from February 1967.

24 Some local authorities issued announcements to publicly address the problems of the epidemic in February 1967. For example, on February 7, 1967, an emergency notification was issued by the town government of Huangshi in Hubei province. The notification’s title was, “We urge you to fight against Epidemic Cerebrospinal Meningitis,” and pointed out that epidemic cerebrospinal meningitis was rampant in Huangshi town and Daye village. The number of patients was growing, and the onset of the disease was acute, with high mortality. Meanwhile, it also stated: “Next spring there will be millions of young revolutionaries arriving at our city, leaving other cities and going straight to the heart of our country in order to share their revolutionary experience; therefore, to prevent and eradicate the disease, we must put the topic down in our agenda, so that all people will place extra emphasis on the matter.”45 This notification was announced in view of the next population mobilization, and Huangshi town had to prepare disease prevention measures to face the restoration of the Great Networking Movement in April.

25 Other provinces lacked medicines. A CIA report stressed that the chaos and mobilization caused by the Cultural Revolution had led to the transmission of the disease, and in provinces like Guangdong, the epidemic was out of control due to the

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shortage of sulfadiazine—a drug used in the prevention and treatment of the disease. In fact, in February 1967, severe shortages of sulfadiazine began to occur elsewhere, leading many Chinese people to turn to traditional medicine. Local health units placed urgent calls to higher echelons for supplies of sulfadiazine.46

26 In the face of such a severe situation and aware of warnings from many local authorities, the CPC Central Committee issued a proclamation on 19 March, 1967 which cancelled the previous plan to restore the movement in spring 1967.47 At the same time, the CPC Central Committee decided to restore school classes so that students could participate in the revolution while they were in their hometowns, and pursuing their education, at the same time, and addressed the question of the epidemic.

Ideologies for eliminating the epidemic

27 After the CPC Central Committee’s announcement (March 3, 1967 that the elimination of the epidemic was a political mission, both central and local governments paid significant attention to the disease, and were willing to spend money and provide resources for preventive programs.48 The CPC Central Committee used two slogans and two ideologies to fight the disease: 1) “Accelerate the revolution, increase production” (zhua geming cu shengchan) and 2) The “Patriotic Health Campaigns” (Aiguoweisheng) already mentioned and used in the context of the Korean War and the schistosomiasis campaigns.

28 When the Cultural Revolution was launched, agricultural and industrial production suffered. An article published in the People’s Daily on September 6, 1966, specified that “the Cultural Revolution is the main focus; we must revolutionize and produce at the same time without any delay.”49 The slogan “Accelerate the revolution, increase production,” one of the main ideologies of the revolution, was emphasized in a People’s Daily article published on September 7, 1966, following Mao’s instructions, where it was stated that revolution and production should not be delayed.50

29 Increasing agricultural and industrial production required a healthy population and effective disease control. As a result, the control and preventive measures of the epidemic also became a significant part of the supreme instruction of the third five- year plan (implemented by the CPC during 1966-1970). Applying the slogan, local authorities put the disease at the center of their activities. For instance, a prevention and treatment notice published in Guangxi Province explained: Apply all effective measures to eliminate diseases that affect people’s health so that we can effectively implement revolution and increase production in order to ensure a smooth proletarian Cultural Revolution. […] According to Chairman Mao’s indication to accelerate revolution and increase production, we must pursue a proletarian Cultural Revolution and actively prevent and treat diseases so that the revolution will run smoothly, this is vital to the development of industrial and agricultural production. […] To prevent and treat meningitis is not a general problem, the problem is to implement the Cultural Revolution and increase production.51

30 The fight against the epidemic was also incorporated into the Patriotic Health Campaigns mentioned above. The Patriotic Health Campaigns, since their implementation in 1952, had aimed to “motivate everyone (dongyuan qilai), decrease disease (jianshao jibing), make changes in customs (yifeng yisu), make changes to the country (gaizai guojia),” and fight for the protection of health and to prevent diseases.

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The CPC regarded the treatment of disease as a way of increasing the strength of the population, and moving forward from a backward stage to a more advanced level. Public health was seen as a strategy to increase productivity, develop industrial and agricultural production, and eventually improve living standards.52 After the end of the Korean War, the focus of the Patriotic Health Campaigns, once restricted to fighting the United States’ alleged biological weapons, became the more general concern of public health and hygiene, and introduced the idea of public health and hygiene as an ongoing, everyday activity. Every household had to clean its home, and everyone was made highly aware of hygiene.

31 Since the 1950s, committees had been operating in every province and city in China to promote, advertise and organize the Patriotic Health Campaigns. Under orders from Chairman Mao and the CPC Central Committee, the campaign essentially mobilized the general public to participate in a national movement for hygiene and disease prevention. It believed that mobilizing the masses, through the spirit of revolution, could be used to solve any post-1950s public health problem. In 1967, the central and local authorities mobilized the masses to carry out preventive measures for cerebrospinal meningitis specifically under the Patriotic Health Campaigns, promoting notably the slogan of Sankai (three opennesses), Sanshai (three sun-dryings), and Sangeli (three isolations).53 This preventive campaign was the major measure taken by the Patriotic Health Campaigns during the winter and spring.54

The central and local strategic policy against epidemic cerebrospinal meningitis

32 On March 3, 1967, the State Council, (according to an epidemic prevention report, submitted by the Ministry of Health), instructed local authorities at all levels to take immediate action to control the disease.55 In February 1967, initiating the preventive measures in every province and teaching the public how to prevent the disease were significant steps in controlling the epidemic. In Hunan province for instance, the following prevention efforts were made: firstly, the CPC Central Committee and the State Council provided medical support, sending medical staff and drugs to the Hunan province (indicating cooperation between the Ministry of Health, the Ministry of Communications, the Department of Railways, and the Department of Commerce). Secondly, Local epidemic elimination offices were established at all levels of government, including provincial, city, county government, community, and production brigade. The offices above the county level were led by military officers, and the duties of each office were clearly assigned. Thirdly, data collected about the epidemic were shared, and a large-scale promotion campaign was launched. Finally, 800 health teams composed of 12,799 medical staff were created, and sent to villages to promote the preventive program, and to treat any patients. From late February to April, a total of 429 patients had been treated.56

33 It is worth noting that some difficulties were also encountered. The disease had spread throughout the villages in Hunan province, but the village health organizations could not control the epidemic due to a lack of preventive measures and necessary drugs.57 China also lacked other medical supplies, such as face masks.58 For example, many medical staff in Guangzhou hospitals became infected with the disease when attending meningitis patients. Many county and city hospitals of Guangdong province urgently

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requested more money to purchase medical tools and drugs, especially first-aid supplies and sulfa drugs. However, local governments did not have enough funding to support the preventive work and treatment of the disease, to purchase the medicines and to pay medical staff.59

34 In February and March 1967, after receiving orders from the highest command of the CPC Central Committee, control centers were established in every province, county and city. These control centers had the role of coordinating prevention efforts, notably by printing and distributing health care handbooks of various forms, and treating meningitis.60 In August 1967, a handbook entitled, The Prevention and Treatment Handbook of Epidemic Cerebrospinal Meningitis, was co-edited by the Sanitation and Anti- epidemic Station, the Children’s Hospital, the Beijing First Hospital of Infectious Diseases and the Beijing Second Hospital of Infectious Diseases, and the Chinese Medical Association. This book is divided into three sections: 1) prevention, 2) diagnosis, and 3) treatment (instructions relating to using sulfur drugs, penicillin and chloramphenicol). It emphasized the importance of preventive measures and also that the government had a significant role to play in health education relating to the disease and in mobilizing public participation. If one compares this handbook with Wang Qihuang’s book (1961), it is clear that this publication further emphasized prevention, including: monitoring the health of people who had been in close contact with patients; providing adequate medical supplies for them; and even advocating the quarantining of epidemic areas in order to decrease the spread of the disease. Finally, the handbook stresses that the public should minimize the possibility of contact with people infected by the disease. For example, in areas where the disease was prevalent, the book advised that people stop public assemblies and cultural/entertainment activities. It recommended that affected villages and production brigades should be isolated if necessary.61

The political struggles among the different factions within the CPC delay the implementation of public health measures

35 As numerous scholars have shown62, the complex power struggles that existed among the different political factions within the CPC at that time may explain why it took so long before any concrete evidence of cooperation between the CPC and the Ministry of Health could be seen.

36 At the beginning of the Cultural Revolution, most central government departments were seized, and government officials attacked by what was later known as the rebel factions (zao fan pai). At the beginning of the Cultural Revolution, these mass organizations criticized government officials suspected of revisionism and took over every government unit. The Ministry of Health was no exception.63 In August 1966, Tao Zhu (the vice-premier of the State Council and the head of the Central Publicity Department) was promoted to the Standing Committee of the CPC Politburo, and assisted Zhou Enlai in handling the daily affairs of state. Prior to February 1967, he was in charge of the Ministry of Health. However, he was attacked verbally by Jiang Qing and the rebel factions, which surrounded and took over the Ministry of Health. Qian Xinzhong, the Minister of Health, was dragged into the political struggle. However, he

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was powerless and could not do anything as he was trapped in a power struggle between Sun Zheng, the secretary of the Ministry of Health, and the rebel factions. While an office to eliminate the cerebrospinal meningitis epidemic had already been established, it could not function under these circumstances.

37 Premier Zhou Enlai was in a difficult situation: on the one hand, he could not oppose Chairman Mao directly and halt the Great Networking; on the other, he had no control over the Ministry of Health until February 1967, when he resumed the cerebrospinal meningitis epidemic control office to promote the prevention and treatment of meningitis. Zhou believed that this was the most urgent issue at that time, and that it should be addressed without delay.64

Conclusion

38 The nationwide cerebrospinal meningitis epidemic in China during 1966-1967 was largely triggered by political factors. The mass mobilization campaign of the Great Networking Movement, launched by the CPC in the first stages of the Cultural Revolution, led over ten million students and Red Guards to travel across the country to share revolutionary experience and worship Mao. All mass pilgrimages facilitate the spread of disease. In this case the ‘pilgrimage’ initially focused on Beijing and the sacred places of the communist party, and later the ‘pilgrims’ travelled throughout the country, even to the remote rural corners, unwittingly spreading the disease. The gathering of crowds, the huge number of travelling students and the period of the year (winter/spring) when this mobilization took place contributed to the rapid spread of epidemic cerebrospinal meningitis throughout the country. Once the disease was so widespread, the epidemic was difficult to contain, not least because of the political struggles among political factions in the CPC which prevented the ending of the mass mobilization movement and the implementation of public health measures.

39 Tracing the history of the cerebrospinal meningitis epidemic at the beginning of the Cultural Revolution, this paper has found a collective memory of the period in which Zhou Enlai developed his heroic image of saving the people from the epidemic. On March 28, 2008, a stele titled Premier Zhou Enlai saves us (Zhou Enlai zongli jiumin beiji) was placed in Dabu county, in , Guangdong province. The inscription illustrates the severe epidemic in Dabu county in early 1968. The stele recalls that at that time a teenager sent an urgent telegram to Chairman Mao, reporting the severe epidemic situation. Once Premier Zhou read its contents, he immediately sent doctors to the epidemic area, and as a result, the disease was quickly and finally brought under control.

40 Is the story true? The author of this paper has no answer at the moment but hopes that more archives and information relating to this epidemic will be released. This will facilitate a deeper understanding of the socio-political situation of the time and the roles of the various actors in handling the epidemic.

Figure 3. Incidence of cerebrospinal meningitis in Guangdong counties

Incidence City/County Case rate Death Source (per 10,000)

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991 (1966) 82664 11.87 100 City (1967) 1036.61 4102 Shantoushizhi 1999 : 406. 20973 366.2 1608 (1968)

Zhongshan City 2478 (1967) 85 Zhongshanshizai 1997 : 1330.

23813 City 1570 Zhaoqingshizhi 1999 : 1213. (1966-67)

8790 1113.08 608 Chenghai County Chenghaixianzhi 1992 : 758. (1966-68) (1967) (1966-68)

Conghua County 1056.35 Conghuaxianzhi 1994 : 939.

1309 (1967) 114 (1967) Dabu County Dabuxianzhi 1992 : 567. 2162 (1968) 140 (1968)

Deqing County 2330 (1967) 118 Deqingxianzhi 1996 : 666.

9182 Dianbai County 1190 458 Dianbaxianzhi 2000 : 953. (1966-67)

Fengkai County 1569 70 Fengkaixianzhi 1998 : 838.

Fengshun County 5804 (1967) 1574.98 250 Fengshunxianzhi 1995 : 855.

1230 (1967) 695 (1967) 78 (1967) Fogangxianzhi 2003 : 839. 223 (1968) 122 (1968) 23 (1967)

Gaoming County 12 (1966) 3 Gaomingxianzhi 1995 : 620.

Jiaoling County 816 (1967) 35 Jiaolingxianzhi 1992 : 608.

3068 (1967) 187 (1967) Jiexisianzhi 1994 : 538. 727 (1968) 69 (1968)

Heyuan County 2387 (1967) Heyuanxianzhi 2000 : 1023.

Heshan County 1953 (1967) 780 108 Heshanxianzhi 2001 : 606.

2088 Hua County 127 Huaxianzhi 1995 : 802. (1966-67)

Huaiji County 4143 410 Huaijixianzhi 1993 : 680.

69 (1966) Huiyang County 2267 (1967) 111 Huiyangshizhi 2003 : 1438. 464 (1968)

Lechang County 378.72 3 Lechangxianzhi 1994 : 474.

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Lianjiang County 2530 179 Lianjiangxianzhi 1995 : 672.

Liannan Yaozu Zizhi Liannan Yaozu Zizhixianxianzhi 364 (1967) 397.8 14 County 1996 : 610.

Lianshan Zhuangzu Lianshan Zhuangzu Yaozu 81 125 14 yaozu zizhi County Zizhixianzhi 1997 : 763.

Longchuan County 1314 270.18 147 Longchuanxianzhi 1994 : 424.

Luoding County 1330 (1966) 122 Luodingxianzhi 1994 : 606.

Mei County 191 Meixianzhi 1994 : 981.

Nanxiong County 6636 109 Nanxiongxianzhi 1991 : 645

Panyu County 3387 656.3 162 Panyushizhi 1995 : 834

Pingyuan County 824 50 Pingyuanxianzhi 1993 : 606.

11140 County 1270 506 Puningxianhi 1995 : 602. (1967)

155 (1966) 18 (1966) 5741 (1967) 283 (1967) Raopingxianzhi 1994 : 890. 2542 (1968) 108 (1968)

Ruyuan Yaozu Zizhixian Ruyuan yaozu zizhixianzhi 1997 : 155 County 695

Qingyuan County 3378 (1967) 584.6 201 Qingyuanxianhi 1995 : 894.

Sanshui County 1546 (1967) 52 Sanshuixianzhi 1995 : 1217.

250.43 Shixingxianzhi 1997 : 843. (1967)

Wengyuan County 1148 51 Wengyuanxianzhi 1997 : 776

10937 1886.9 426 Wuhuaxianzhi 1991 : 551. (1967)

9745 Xinhui County 1414.6 266 Xinhuixianzhi 1995 : 1002. (1966-67)

Xinxing County 1322 (1967) 70 Xinxingxianzhi 1993 : 614.

Xinyi County 4228 (1967) 340 Xinyixianzhi 1993 : 854.

Yangchun County 4452 (1967) 312 Yangchunxianzhi 1996 : 886.

9008 County 418 Yangjiangxianzhi 2000 : 939. (1966-68)

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7.7 (1966) 22 (1966) 1 (1966) Yunan County 324.37 Yunanxianzhi 1995 : 839. 955 (1967) 60 (1967) (1967)

Yunfu County 1639 (1967) 82 Yunfuxianzhi 1995 : 713.

Zijin County 2315 (1967) 133 Zijinxianzhi 1994 : 798.

BIBLIOGRAPHY

Primary Sources

Political Archives

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• “Zhonggong zhongyang guanyu nongcun wuchanjieji wenhua da geming de zhishi (can an)” (Directive of the CPC Central Committee Concerning the Cultural Revolution in the Countryside [Draft]) 中共中央關於農村無產階級文化大革命的指示 (草案) (15.12.1966): 137-138.

• “Zhonggong zhongyang guanyu tingzhi quanguoda de tongzhi” (Notice of the CPC Central Committee Concerning the Suspension of the Great Networking all over the Country) 中共中央關 於停止全國大串連的通知 (19.03.1967): 377.

• “Zhonggong zhongyang guanyu xian yi xia nongcun wenhua da geming de guiding” (Regulations of the CPC Central Committee Concerning the Cultural Revolution in the County Level) 中共中央關於縣以下農村文化大革命的規定 (14.09.1966): 77-78.

• “Zhonggong zhongyang, guowuyuan guanyu geming shisheng he Hongweibing jinxing buxing chuanlian wenti yu tongzhi” (Notice of the CPC Central Committee and the State Council Concerning the Question of Exchange of Revolutionary Experience on Foot by Revolutionary Teachers and Students, and Red Guards) 中共中央、國務院關於革命師生和紅衛兵進行步行串 連問題與通知 (03.02.1967): 225-226.

• “Zhonggong zhongyang, guowuyuan guanyu geming shisheng jinxing buxing chuanlian wenti yu tongzhi” (Notice of the CPC Central Committee and the State Council Concerning the Question

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of Revolutionary Teachers and Students Exchanging Revolutionary Experience) 中共中央、國務 院關於革命師生進行步行串連問題與通知 (16.11.1966): 107-108.

• “Zhonggong zhongyang, guowuyuan guanyu geming shisheng jinxing geming chuanlian wenti de buchong tongzhi” (Supplementary Circular of the CPC Central Committee and the State Council Concerning the Question of Exchange of Revolutionary Experience by Revolutionary Teachers and Students) 中共中央、國務院關於革命師生進行革命串連問題的補充通知 (01.12.1966): 125-126.

ZHONGGONG ZHONGYAO LISHI WENXIAN ZILIAO HUIBIAN (Collection of Important Sources related to the History of Communist China) 中共重要歷史文獻資料匯編. 1997. Los Angeles, Zhongwen chubanwu fuwu zhongxin.

• “Chen Yi tongzhi jiuyue shisiri zai waiwenjiu quanti zhigong da hui shang de jiang hua (Comrade Chen Yi’s Speech held in the Plenary Meeting of the Industrial Organization.14.09.1966) 陳毅同志九月十四日在外文局全體職工大會上的講話.” vol. 13, no. 2: 73.

• “Li Xiannian fuzongli jiejian sun qian huang ji bu jiguan gepai de jianghua” (Discourse among Vice-Premier Li Xiannian, Sun, Qian, Huang and All Factions during Li’s Reception. 09.03.1967) 李 先念副總理接見孫、錢、黃及部機關各派的談話. vol. 13, no. 7: 94-95.

• “Li Xiannian fuzongli jiejian weishengbu jiguan ge qunzhong zuzhi daibiao shi de jianghua” 李 先念副總理接見衛生部機關各群眾組織代表時的講話 (Speech Given by Vice- Premier Li Xiannian While Receiving the Representatives of All Mass Organizations of the Ministry of Health.10.03.1967). vol. 13, no. 7: 95-98.

• “Qi Benyu tongzhi jiuyue liuri zai er qi jichechang gongju chejian jianghua jiyao” (Summary of Speech Given by Comrade Qi Benyu at Tool Room of the Feb. 7th Locomotive Works on 6 Sept. 6.09.1966) 戚本禹同志九月六日在二七機車廠工具車間講話紀要. vol. 13, no. 2: 18.

• “Tao Zhu shiyue ershisiri zai zhongnanhai jiejian shoudu dazhuan yuanxiao hongweibing geming zaofan zongsilingbu bufen xuexiao daibiao shi de jianghua” (Tao Zhu Received the Representatives of Capital Higher Education Institutes’ Red Guards in Revolutionary Rebels General Headquarters at Zhongnanhai on 24 Oct. 24.10.1966) 陶鑄十月二十四日在中南海接見首 都大專院校紅衛兵革命造反總司令部部分學校代表時的講話. vol. 13, no. 2: 240.

• “Wu de tongzhi zai gongren tiyuguan guan yu jiedai waidi geming shisheng de jianghua” 吳德同 志在工人體育館關於接待外地革命師生的講話 (Comrade Wu De’s Speech Regarding the Reception of Revolutionary Teachers and Students from Other Places at the Workers’ Stadium. 13.12.1966). vol. 13, no. 4: 56-57.

• “Zhang Chunqiao tongzhi zai zhengxie litang de jianghua” (Comrade Zhang Chunqiao’s Speech at the People’s Republic of China Political Consultative Auditorium. 28.10.1966) 張春橋同志在政 協禮堂的講話. vol. 13, no. 2: 265.

• “Zhou Enlai dui shoudu gaoxiao hongweibing de jianghua” (Zhou Enlai’s Speech to the Capital Higher Education Institutes’ Red Guards. 9.12.1966) 周恩來對首都高校紅衛兵的講話. vol. 13, no. 4: 74.

• “Zhou Enlai tongzhi zai zhongyang gongzuo huiyi de jianghua” (Comrade Zhou Enlai’s Speech at the Central Work Conference. 28.10.1966) 周恩來同志在中央工作會議上的講話. vol. 13, no. 2: 268-270.

• “Zhou zongli dui jiedai renyuan de jianghua” (Premier Zhou’s Speech to the Receptionists. 12.01.1967) 周總理對接待人員的講話. vol. 13, no. 5: 129.

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• “Zhou zongli ji er yue jiu ri de jianghua” (Premier Zhou’s Speech on 9 Dec. 09.12.1966) 周總理十 二月九日的講話. vol. 13, no. 4: 73-76.

• “Zhou zongli jiejian weishengbu hongsezaofantuan hongqizhandoutuan gelianzongbu dongfanghonggongshe sige zuzhi daibiao he bulingdao shi jianghua” (Premier Zhou’s Speech to the Four Organizational Representatives and Leaders of Red Regiment of Rebellion, Red Flag Combat Regiment, Revolutionary Union and East Is Red Commune, of the Ministry of Health. 24.03.1967) 周總理接見衛生部紅色造反團、紅旗戰鬥團、革聯總部、東方紅公社四個組織代表 和部領導時講話. vol. 13, no. 7: 216-232.

Archives about the Epidemic from Guangdong Provincial Archives, Handbooks, and Press

“Dui liunao fangzhi youguan wenti de yijian” (Opinions Regarding the Question of the Prevention and Treatment of Epidemic Cerebrospinal Meningitis) 對流腦防治有關問題的意見 (3 March 1967). Guangdong Provincial Archives no. 317–1-148: 26-27.

“Guanyu qieshi zuohao fangzhi liuxingxing naojisuimoyan gongzuo de jinji tongzhi” (Urgent Notice Prone to the Conscientiously Doing Well the Work to Prevent and Treat Epidemic Cerebrospinal Meningitis) 關於切實做好防治流行性腦脊髓膜炎工作的緊急通知 (20.02.1967). In GUANGXI ZHUANGZU ZIZHIQU FANGZHI LIUNAO ZHIHUIBU 廣西壯族自治區防治流腦指揮部 and GUANGXI ZHUANGZU ZIZHIQU WEISHENG JIAOYUSUO 廣西壯族自治區衛生教育所 (eds.), Fangzhiliuxingxing naojisuimoyan shouce (Handbook for the Prevention and Treatment of Epidemic Cerebrospinal Meningitis) 防治流行性腦脊髓膜炎手冊. No publication data: 1-6.

“Hongweibing bupa yuanzheng nan” (The Red Guards do not Fear Long March) 紅衛兵不怕遠征 難. People’s Daily, 22.10. 1966: 1.

“Liunao de yufang” (The Prevention of Epidemic Cerebrospinal Meningitis) 流腦的預防 (20.02.1967). In GUANGXI ZHUANGZU ZIZHIQU FANGZHI LIUNAO ZHIHUIBU 廣西壯族自治區防治流腦指揮部 and GUANGXI ZHUANGZU ZIZHIQU WEISHENG JIAOYUSUO 廣西壯族自治區衛生教育所 (eds.), Fangzhiliuxingxing naojisuimoyan shouce (Handbook forthe Prevention and Treatment of Epidemic Cerebrospinal Meningitis) 防治流行性腦脊髓膜炎手冊. No publication data: 9-13.

“Quansheng fangzhi liuxingxing naojisuimoyan gongzuo zongjie” (Summary on the Works of the Provincial Prevention and Treatment of Epidemic Cerebrospinal Meningitis) 全省防治流行性腦 脊髓膜炎工作總結 (19.05.1967). In HUNANSHENG FANGZHI NAOMOYAN ZHIHUIBU and HUNANSHENG WEISHENGTING 湖南省防治腦膜炎指揮部、湖南省衛生廳 (eds.), Hunansheng fangzhi liuxingxing naojisuimoyan jingyan huibian (Collection on the Experiences of the Prevention and Treatment of Epidemic Cerebrospinal Meningitis in Hunan Province) 湖南省防治流行性腦脊髓膜炎經驗匯編. No publication data: 26-32.

“Xian fangzhi liunao gongzhu huiyijiyao” (Summary of Provincial Meeting of the Prevention and Treatment of Epidemic Cerebrospinal Meningitis) 省防治流腦工作會議紀要 (13.04.1967). Guangdong Provincial Archives no. 317-1-148: 18.

“Xian junguan weisheng xiaozu guanyu canjia yufang lounao yiwu renyuan xiangshou baojian jintie wenti de lianhe tongzhi” (Joint Notice by Small Group of Health Provincial Military Officials Pertaining to Receiving Health Allowance for the Medical Staff Participating in the Prevention of Epidemic Cerebrospinal Meningitis) 省軍管衛生小組關於參加預防流腦醫務人員享受保健津貼 問題的聯合通知 (04.07.1967). Guangdong Provincial Archives no. 295–1-234: 90.

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“Zhonggong zhongyang guowuyuan zhishi” (Central Committee and State Council Directive) 中 共中央、國務院指示 (03.03.1967). In HUNANSHENG FANGZHI NAOMOYAN ZHIHUIBU and HUNANSHENG WEISHENGTING 湖南省防治腦膜炎指揮部、湖南省衛生廳 (eds.), Hunansheng fangzhi liuxingxing naojisuimoyan jingyan huibian (Collection on the Experiences of the Prevention and Treatment of Epidemic Cerebrospinal Meningitis in Hunan Province) 湖南省防治流行性腦脊髓膜炎經驗匯編. No publication data: 1.

“Zhua ge ming, cu sheng chan” (Accelerate Revolution, Increase Production) 抓革命促生產. People’s Daily, September 7, 1966: 1.

“Zui jinji huxu jinji dongyuan qilai wei xunsu pumie liunao er douzheng” (We urge you to fight against Epidemic Cerebrospinal Meningitis) 最緊急呼吁—緊急動員起來，為迅速撲滅流腦而鬥 爭 (07.02.1967), in HUBEIXIAN WEISHENG FANGYIZHAN 湖北省衛生防疫站 (ed.) (February 1967). Liuxingxingnaomoyan fangzhi shouce (Handbook for the Prevention and Treatment of Epidemic Cerebrospinal Meningitis) 流行性腦膜炎防治手冊. No publication data.

ZHANGJIAKOU ZHUANQU FANGBING OFFICE 張家口專區防病辦公室 (ed.), Liunao fangzhi ziliao (Materials for the Prevention and Treatment of Epidemic Cerebrospinal Meningitis) 流腦防治資料. No publication data.

Local Gazetteers

Anhui shengzhi weishengzhi (Health Gazetteer of Anhui Province) 安徽省志衛生志. (1996). Hefei, Anhui renmin chubanshe.

Beijingzhi weishengzhi (Health Gazetteer of Beijing) 北京志.衛生志. (2003). Beijing, Beijing chubanshe.

Chenghai xianzhi (Chenghai County Gazetteer) 澄海縣志 (1992). Guangzhou, Guangdong renmin chubanshe.

Conghua xianzhi (Conghua County Gazetteer) 從化縣志 (1994). Guangzhou, Guangdong renmin chubanshe.

Dabu xianzhi (Dabu County Gazetteer) 大埔縣志 (1992). Guangzhou, Guangdong renmin chubanshe.

Deqing xianzhi (Deqing County Gazetteer) 德慶縣志 (1996). Guangzhou, Guangdong renmin chubanshe.

Dianbai xianzhi (Dianbai County Gazetteer) 電白縣志 (2000). Beijing, Zhonghua shuju.

Fengkai xianzhi (Fangkai County Gazetteer) 封開縣志 (1998). Guangzhou, Guangdong renmin chubanshe.

Fengshun xianzhi (Fenghun County Gazetteer) 豐順縣志 (1995). Guangzhou, Guangdong renmin chubanshe.

Fogang xianzhi (Fogang County Gazetteer) 佛岡縣志 (2003). Beijing, Zhonghua shuju.

Gansu shengzhi weishengzhi (Health Gazetteer of Gansu Province) 甘肅省志衛生志. (1995). Lanzhou, Gansu wenhua chubanshe.

Gaomingxianzhi (Gaoming County Gazetteer) 高明縣志 (1995) Guangzhou, Guangdong renmin chubanshe.

Guangdong shengzhi weishengzhi (Health Gazetteer of Guangdong Province) 廣東省志衛生志 (2003). Guangzhou, Guangdong renmin chubanshe.

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Guangxi tongzhi yiliao weishengzhi (Health Gazetteer of Guangxi Province) 廣西通志醫療衛生志 (1999). Nanning, Guangxi renmin chubanshe.

Guangzhou shizhi. Gongchandangzhi (1921-1990) (Guangzhou City Gazetteer. Record of Communist Party of China) 廣州市志. 共產黨志 (1997). Guangzhou, Zhonggong Guangzhoushiwei dangzhi bianzuan lingdao xiaozu bangongshi.

Hainan shengzhi weishengzhi (Health Gazetteer of Hainan Province) 海南省志衛生志 (2001). Beijing, Fangzhi chubanshe.

Heilongjiang shengzhi weishengzhi (Health Gazetteer of Heilongjiang Province) 黑龍江省志衛生志 (1998). Ha’erbin, Heilongjiang renmin chubanshe.

Henan shengzhi weishengzhi (Health Gazetteer of Henan Province) 河南省志衛生志 (1991). Zhengzhou, Henan renmin chubanshe.

Heshan xianzhi (Heshan County Gazetteer) 鶴山縣志 (2001). Guangzhou, Guangdong renmin chubanshe.

Heyuan xianzhi (Heyuan County Gazetteer) 河源縣志 (2000). Guangzhou, Guangdong renmin chubanshe.

Huaiji xianzhi (Huaji County Gazetteer) 懷集縣志. (1993). Guangzhou, Guangdong renmin chubanshe.

Hua xianzhi (Hua County Gazetteer) 花縣志 (1995). Guangzhou, Guangdong renmin chubanshe.

Huiyang xianzhi (Huiyang County Gazetteer) 惠陽縣志 (2003). Guangzhou, Guangdong renmin chubanshe.

Hunan shengzhi yiyao weishengzhi (Health Gazetteer of Hunan Province) 湖南省志醫藥衛生志 (1998). Changsha, Hunan renmin chubanshe.

Jiangsu shengzhi weishengzhi (Health Gazetteer of Jiangsu Province) 江蘇省志衛生志 (2003). Nanjing, Jiangsu renmin chubanshe.

Jiangxisheng weishengzhi (Health Gazetteer of Jiangxi Province) 江西省衛生志 (1997). Hefei, Huangshan shushe.

Jiaoling xianzhi (Jiaoling County Gazetteer) 蕉嶺縣志 (1992). Guangzhou, Guangdong renmin chubanshe.

Jiexi xianzhi (Jiexi County Gazetteer) 揭西縣志. (1994). Guangzhou, Guangdong renmin chubanshe.

Jilinshengzhi weishengzhi (Health Gazetteer of Jilin Province) 吉林省志衛生志 (1992). Changchun, Jilin renmin chubanshe.

Jinggangshanzhi (Jianggang Mountain Gazetteer) 井岡山志 (1997). Beijing, Xinhua chubanshe.

Lechang xianzhi (Lechang County Gazetteer) 樂昌縣志 (1994). Guangzhou, Guangdong renmin chubanshe.

Lianjiang xianzhi (Lianjiang County Gazetteer) 廉江縣志. (1995). Guangzhou, Guangdong renmin chubanshe.

Liannan Yaozu zizhi xianzhi (Liannan Yaozu Zizhi County Gazetteer) 連南瑤族自治縣縣志 (1996). Guangzhou, Guangdong renmin chubanshe.

Lianshan Zhuangzu Yaozu zizhi xianzhi (Lianshan Zhuangzu Yaozu Zizhi County Gazetteer) 連山壯族瑤 族自治縣縣志 (1997). Beijing, sanlian shudian.

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Liaoning shengzhi weishengzhi (Health Gazetteer of Liaoning Province) 遼寧省志衛生志 (1999). Shenyang, Liaoning renmin chubanshe.

Longchuan xianzhi (Longchuan County Gazetteer) 龍川縣志. (1994). Guangzhou, Guangdong renmin chubanshe.

Louding xianzhi (Louding County Gazetteer) 羅定縣志. (1994). Guangzhou, Guangdong renmin chubanshe.

Mei xianzhi (Mei County Gazetteer) 梅縣志. (1994). Guangzhou, Guangdong renmin chubanshe.

Nanxiong xianzhi (Nanxiong County Gazetteer) 南雄縣志. (1991). Guangzhou, Guangdong renmin chubanshe.

Panyu xianzhi (Panyu County Gazetteer) 番禺縣志. (1995). Guangzhou, Guangdong renmin chubanshe.

Pingyuan xianzhi (Pingyuan County Gazetteer) 平遠縣志. (1993). Guangzhou, Guangdong renmin chubanshe.

Puning xianzhi (Puning County Gazetteer) 普寧縣志. (1995). Guangzhou, Guangdong renmin chubanshe.

Qingyuan xianzhi (Qingyuan County Gazetteer) 清遠縣志. (1995). no publication data.

Raoping xianzhi (Raoping County Gazetteer) 饒平縣志. (1994). Guangzhou, Guangdong renmin chubanshe.

Ruyuan Yaozu Zizhi xianzhi (Ruyuan Yaozu Zizhi County Gazetteer) 乳源瑤族自治縣志. (1997). Guangzhou, Guangdong renmin chubanshe.

Sanshui xianzhi (Sanshu County Gazetteer) 三水縣志. (1995). Guangzhou, Guangdong renmin chubanshe.

Shaanxi shengzhi weishengzhi (Health Gazetteer of Shaanxi Province) 陝西省志衛生志. (1996). Xian, Shaanxi renmin chubanshe.

Shandongsheng weishengzhi (Health Gazetteer of Shandong Province) 山東省衛生志. (1992). Jinan, Shandong renmin chubanshe.

Shantou shizhi (Shantou City Gazetteer) 汕頭市志. (1999). Beijing, Xinhua chubanshe.

Shanxi tongzhi weisheng yiyaozhi weishengpian (Health Gazetteer of Shanxi Province) 山西通志衛生醫 藥志衛生篇. (1997). Beijing, Zhonghua shuju.

Shixing xianzhi (Shixing County Gazetteer) 始興縣志. (1997). Guangzhou, Guangdong renmin chubanshe.

Sichuan shengzhi yiyao weishengzhi (Health Gazetteer of Sichuan Province) 四川省志醫藥衛生志. (1995) Chengdu, Sichuan cishu chubanshe.

Wengyuan xianzhi (Wengyuan County Gazetteer) 翁源縣志. (1997). Guangzhou, Guangdong renmin chubanshe.

Wuhua xianzhi (Wuhua County Gazetteer) 五華縣志. (1991). Guangzhou: Guangdong renmin chubanshe.

Xinhui xianzhi (Xinhui County Gazetteer) 新會縣志. (1995). Guangzhou, Guangdong renmin chubanshe.

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Xinjiang tongzhi weishengzhi (Health Gazetteer of Xinjiang Province) 新疆通志衛生志. (1996). Wulumuqi, Xinjiang renmin chubanshe.

Xinxing xianzhi ( Gazetteer) 新興縣志. (1993). Guangzhou, Guangdong renmin chubanshe.

Xinyi xianzhi (Xinyi County Gazetteer) 信宜縣志. (1993). Guangzhou, Guangdong renmin chubanshe.

Yangchunxianzhi (Yangchun County Gazetteer) 陽春縣志. (1996). Guangzhou, Guangdong renmin chubanshe.

Yangjiang xianzhi (Yangjiang County Gazetteer) 陽江縣志. (2000). Guangzhou, Guangdong renmin chubanshe.

Yunan xianzhi (Yunan County Gazetteer) 郁南縣志. (1995). Guangzhou, Guangdong renmin chubanshe.

Yunfu xianzhi (Yunfu County Gazetteer) 雲浮縣志. (1995). Guangzhou, Guangdong renmin chubanshe.

Zhongshan shizhi (Zhongshan City Gazetteer) 中山市志 (1997). Guangzhou, Guangdong renmin chubanshe.

Zijin xianzhi ( Gazetteer) 紫金縣志 (1994). Guangzhou, Guangdong renmin chubanshe.

Zhaoqing shizhi (Zhaoqing City Gazetteer) 肇慶市志. (1999). Guangzhou, Guangdong renmin chubanshe.

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APPENDIXES

Glossary

Aiguo weisheng 愛國衛生 Anhui 安徽

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Beijing 北京 Changsha 長沙 Changshao 長韶 Chenghai xian 澄海縣 Chenzhou 郴州 Chongqing 重慶 Conghua xian 從化縣 Da chuan lian 大串連 Dabu (xian) 大埔(縣) Daye 大冶 Dazhai 大寨 Deng Tietao 鄧鐵濤 Deqing xian 德慶縣 Dianbai xian 電白縣 Difangzhi 地方誌 dongyuan qilai 動員起來 Fengkai xian 封開縣 Fengshun (xian) 豐順(縣) Fogang xian 佛岡縣 Fujian 福建 gaizai guojia 改造國家 Gansu 甘肅 Gaoming xian 高明縣 Guandu 官渡 Guangdong 廣東 Guangxi 廣西 Guangzhou 廣州 Hainan 海南 Hebei 河北 Heilongjiang 黑龍江 Henan 河南 Hengyang 衡陽 Heshan xian 鶴山縣 Heyuan xian 河源縣 Hong wei bing 紅衛兵 Hua (xian) 花(縣) Huaiji xian 懷集縣 Huangshi 黃石 Hubei 湖北 Huiyang xian 惠陽縣 Hunan 湖南 Jiang Qing 江青 Jiangsu 江蘇 Jiangxi 江西 jianshao jibing 減少疾病 Jiaoling xian 蕉嶺縣 Jiexi xian 揭西縣 Jilin 吉林

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Jinggang Mountains 井岡山 Lechang xian 樂昌縣 Lianjiang xian 廉江縣 Liannan Yaozu Zizhi 連南瑤族自治 Lianshan Zhuangzu Yaozu zizhixian 連山壯族瑤族自治縣 Liaoning 遼寧 Longchuan xian 龍川縣 (xian) 羅定(縣) Mao Zedong 毛澤東 Meixian 梅縣 Meizhou 梅州 Nanxiong xian 南雄縣 Ningxia 寧夏 Panyu xian 番禺縣 Pingyuan (xian) 平遠(縣) Puning xian 普寧縣 Qian Xinzhong 錢信忠 青海 Qingyuan xian 清遠縣 Quanguo dachuanlian 全國大串連 Raoping (xian) 饒平(縣) Renmin gongshe 人民公社 Renmin ribao 人民日報 Ruyuan Yaozu zizhi xian 乳源瑤族自治縣 Sangeli 三隔離 Sankai 三開 Sanshai 三曬 Sanshui (xian) 三水(縣) Shaanxi 陝西 Shandong 山東 Shanghai Ruijin 上海瑞金 Shantou 汕頭 Shanxi 山西 Shaoshan 韶山 Shixing xian 始興縣 Si Jiu 四舊 Sichuan 四川 Sun Zheng 孫正 Tao Zhu 陶鑄 Tiananmen 天安門 Wang Qihuang 王耆煌 Weishengzhi 衛生志 Wengyuan (xian) 翁源(縣) Wuhua (xian) 五華(縣) Xinhui (xian) 新會(縣) Xinjiang 新疆 Xinxing xian 新興縣 Xinyi xian 信宜縣

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Yan’an 延安 Yangchun (xian) 陽春(縣) Yangjiang xian 陽江縣 yifeng yisu 移風易俗 Yueyang 岳陽 Yunan xian 郁南縣 Yunfu xian 雲浮縣 Zao fan pai 造反派 Zhaoqing 肇慶 Zhongshan 中山 Zhou Enlai zongli jiumin beiji 周恩來總理救民碑記 Zhou Enlai 周恩來 Zhoubei 周陂 zhua geming, cu shengchan 抓革命, 促生產 Zhuzhou 株洲 Zijin xian 紫金縣 Zunyi 遵義

NOTES

2. Chen 2007: 456-482. 3. Endicoot 1998. 4. Fan 2008: 176-187; Gross 2010. 5. Xiao 2004: 498-514; Rogaski 2004: 285-299; Hu 2013: 94-117; Fan 2010: 277-293; Hung 2010: 400-420. 6. Zuo 1997: 12; Patterson 1993: 878; National Immunization Program, Chinese Center for Disease Control and Prevention. 7. Cui 1986: 28-35; Hipgrave 2011: 224-238. 8. Schwartz 1989: S 118-124; Baltimore 2009: 495-517. 9. For more details from medical perspective, see World Health Organization 1998. 10. World Health Organization 1998: 15; Saez-Liorens 2003; Umaru 2013: 1-30. For epidemiological characteristics of Cerebrospinal Meningitis in China, see Xue 2009: 26-35. 11. Hu 1981: 61. 12. In 1975, 100/100,000 was defined as the highest incidence of the epidemic cerebrospinal meningitis. See Hu 1981: 61; Wang 1992: 5267-5282. 13. Huang 2009: 343-344. 14. Health gazetteers do not usually cite the references from which they extract numbers and information, so we are never sure where the numbers came from. Although the figures are not totally reliable, they may reflect the trend of the dissemination of epidemic cerebrospinal meningitis over the early period of the Cultural Revolution, for which we have no other figures. As picture 1 shows (xxx), the CPC had not released any official figures regarding the epidemic at that time. In a meeting, Zhou Enlai discussed with representatives from the rebel factions whether to publish the confidential figures pertaining to the meningitis epidemic. Zhonggong zhongyao lishi wenxian ziliao huibian1997, vol. 13, no. 7: 216-232. 15. For more information on the Red Guards, see Chan 1985; Walder 2009. 16. See notably Yan 1989: 75-88; Wang 1996: 127-138. 17. On the Great Networking Movement, see Guo 2006: 105-107; Yang 2000: 379-406; Yan 1993. 18. Bu 2008: 329-332.

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19. These places had something special: the Jinggang Moutains in Hunan were regarded as the cradle of the CPC, since Mao had led a group of peasants there in 1926. Yan’an, in Shaanxi, had been the base of the Chinese Communist Party from 1935 to 1949. It was also the end of the Long March (10/1934-10/1936). Dazhai village, in Shanxi, was chosen to implement the agricultural model that Mao proposed in 1963. Zunyi, in Guizhou province, had been the place of a crucial CPC meeting in January 1935. Shaoshan, in Hunan province, is the birth place of Mao Zedong. 20. Denton 2012: 248. 21. The local gazetteer reported 300 cases of epidemic cerebrospinal meningitis and the death of 18 patients Jinggangshanzhi 1997: 25, 578. 22. CCP Documents of the Great Proletarian Cultural Revolution 1966-1967 1968 (01.12.1966): 125-126; (03.02.1967): 225-226. 23. Yan 1989: 129-135; Bu 2008: 255-269. In China, the spread pattern of the epidemic cerebrospinal meningitis is from the northern to southern region. Wu 1991: 136-139. 24. Deng 2006: 620-624 and MacFarquhar & Schoenhals 2006: 113. 25. Zhonggong zhongyao lishi wenxian ziliao huibian 1997, vol. 13, no. 4: 74. 26. Zhonggong zhongyao lishi wenxian ziliao huibian 1997, vol. 13, no. 4: 73-76; vol. 13, no. 2: 268. 27. Zhonggong zhongyao lishi wenxian ziliao huibian 1997, vol. 13, no. 4: 56-57. 28. The historian Ge Zhaoguang recalled his experience of participating in the Great Networking Movement, traveling from Guiyang to Beijing by train in 1966. He described the poor living condition when he was staying at Tsinghua University, Beijing. Ge 2011. Overcrowded sleeping arrangements is an important factor in the spread of the disease. See Baltimore 2009: 500-501. 29. Zhonggong zhongyao lishi wenxian ziliao huibian 1997, vol. 13, no. 2: 240; vol. 13, no. 2: 265; vol. 13, no. 2: 268. Hospitals in Beijing were full of patients who suffered from respiratory and digestive disease. Zhang 1997: 22-24. 30. CCP Documents of the Great Proletarian Cultural Revolution 1966-1967 1968 (12.11.1966): 96-97. 31. In December 1966, Over 1.6 million Red Guards from various provinces had reached Guangzhou for the Great Networking Movement, a destination widely encouraged by the central government. GuangzhoushizhiGongchandangzhi 1997: 173; Zhonggong zhongyao lishi wenxian ziliao huibian 1997, vol. 13, no. 2: 73. 32. Hunanshengzhi Yiyaoweishengzhi 1988: 163. Deng 2006: 623 cites an archival document related to the epidemic in Guangdong province. In this province, the disease spread widely along the Guangzhou- highway. Heshanxianzhi 2001: 606. In Shanxi province, the disease also spread along the railway. Shanxitongzhi Weisheng Yiyaozhi Weishengpian 1997: 455. 33. For more examples, see Xinhuixianzhi 1995: 1002; Yangchunxianzhi 1996: 886; LiannanYaozu Zizhixianxianzhi 1996: 610; Wengyuanxianzhi 1997: 776. 34. CCP Documents of the Great Proletarian Cultural Revolution 1966-1967 1968 (15.12.1966): 137-138. 35. CCP Documents of the Great Proletarian Cultural Revolution 1966-1967 1968 (14.09.1966): 77-78; Zhonggong zhongyao lishi wenxian ziliao huibian 1997, vol. 13, no. 5: 129; Red Guards also considered that they should go to the villages and promote the revolutionary experience to the peasants. Zhang 2003: 136. 36. The records of Zhongshan city, Zhaoqing city, Raoping county, Fengshun county, Luoding county, Pingyuan county, Hua county and Wuhua county stated that the disease was brought from other places by the students participating in the Great Networking Movement. The first case of the disease in Sanshui county was discovered in 1967, and the patient was a student from another province. Also, the first case of the disease in Hua county was discovered in 1966, and the patient was a Shanghai student. Sanshuixianzhi 1995: 1217. Huaxianzhi 1995: 802. 37. In Wuhua county, for instance, the disease was prevalent in 15 People’s Communes, 3 towns and 313 brigades in 1967. Wuhuaxianzhi 1991: 551.

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38. Chen 1987: 162; Liu 2006: 102-123. 39. “Hongweibing bupa yuanzheng nan” 1966. 40. The revolutionary organizations published a notice which stated that the Great Networking Movement was a great and new creation, and urged students not to stay in big cities but to learn from the workers and the peasants. Zhonggong zhongyao lishi wenxian ziliao huibian 1997, vol. 13, no. 2: 270. 41. Wang 1961. 42. Wang 1961. 43. Red Guards committed many acts of violence. See Wang 1996: 17-36; White 1989; Lu 1995: 533-542. The office of meningitis in Guangdong province stated that enemies of the people spread the rumor that “eradicating four olds caused epidemic cerebrospinal meningitis.” Guangdongsheng liunao office 1967: 59. 44. CCP Documents of the Great Proletarian Cultural Revolution 1966-1967 1968 (16.11.1966): 107-108. 45. “Zui jinji huxu jinji dongyuan qilai wei xunsu pumie liunao er douzheng” 1967. 46. Carey 1967. Although the United States of America (US) did not have much information relating to the Chinese outbreak of epidemic cerebrospinal meningitis, US officials were extremely concerned, believing that the situation was both serious and unprecedented. In Hong Kong, the CIA communicated with the travelers travelling between Hong Kong and Guangzhou in an effort to understand the circumstances of the epidemic in mainland China from 1966-1967. 47. CCP Documents of the Great Proletarian Cultural Revolution 1966-1967 1968 (19.03.1967): 377. 48. Zhonggong zhongyang guowuyuan zhishi 1967: 1. 49. Zhonggong zhongyao lishi wenxian ziliao huibian 1997, vol. 13, no. 2: 18. 50. “Zhua ge ming cu sheng chan” 1966: 1. 51. “Guanyu qieshi zuohao fangzhi liuxingxing naojisuimoyan gongzuo de jinji tongzhi” 1967: 1. 52. Xiao 2004: 498-514. 53. “Three opennesses,” “three sun-dryings,” and “three isolations” are preventive measures designed to confront the epidemic. “Three opennesses” includes: 1) building more windows in the house; 2) enlarging the size of the windows; and 3) keeping windows open frequently. “Three sun-dryings” consists of: 1) drying clothes in the sun; 2) drying beds in the sun; and 3) sunbathing. Finally, “three isolations” involves the isolation of 1) patients; 2) relatives; and 3) the community. 54. Hubeisheng weisheng fangyizhan 1967: 9; Zhangjiakou zhuanqu fangbing office no publication data: 4-5; “liunao de yufang” 1967: 11-12. 55. “Zhonggong zhongyang guowuyuan zhishi” 1967: 1. 56. “Quansheng fangzhi liuxingxing naojisuimoyan gongzuo zongjie” 1967: 26-32. 57. “Quansheng fangzhi liuxingxing naojisuimoyan gongzuo zongjie” 1967: 26-32. 58. Deng 2006: 623. 59. “Xian fangzhi liunao gongzhu huiyijiyao” 1967: 18; “Dui liunao fengzhi youguan wenti de yijian” 1967: 26-27; “Xian junguan weisheng xiaozu guanyu canjia yufang lounao yiwu renyuan xiangshou baojian jintie wenti de lianhe tongzhi” 1967: 90. 60. Deng 2006: 623. 61. The Sanitation and Anti-epidemic Station 1967. 62. Taylor 2005; Scheid 2013: 243. 63. Deng 2006: 623. 64. Zhonggong zhongyao lishi wenxian ziliao huibian 1997, vol. 13, no. 7: 216-232; vol. 13, no. 7: 94-95; vol. 13, no. 7: 95-98.

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ABSTRACTS

This paper explores the cerebrospinal meningitis epidemic during the early stages of China’s Cultural Revolution (1966-1976). Based on provincial archives, health gazetteers and local gazetteers from different provinces and counties, as well as on medical handbooks, this article traces the course of the epidemic, and investigates the reasons that led to this particular epidemic, which started in Beijing and the revolution shrines, before spreading into the countryside.

Cet article analyse l’épidémie de méningite cérébrospinale qui se développe dans la première phase de la Révolution culturelle (1966-1976). S’appuyant sur des sources diverses incluant archives et chroniques locales, monographies de santé publique et manuels de médecine, cette contribution retrace l’histoire de cette épidémie et met en lumière les différents facteurs qui contribuèrent à l’expansion de la maladie depuis Pékin et les grands lieux de la révolution vers l’intérieur des campagnes.

本文研究文化大革命初期流行性腦脊髓膜炎(簡稱流腦)大流行的原因。從各省各縣所編纂衛生 志，都明確地指明在 1966 至 1967 年間，由於毛澤東支持紅衛兵和革命師生進行全國大串連， 交流革命經驗，導致大量人口流動。大量紅衛兵和學生湧入北京，希望一睹毛主席的風采； 另方面，紅衛兵和學生向全國的革命聖地、廣州等地方進發。因此，全國大串連導致全國性 流腦爆發。中共中央沒有及時進行撲滅流腦的計畫，當中原因涉及若干政治因素。直到1967年 初，中共中央決定停止串連，才開展撲滅流腦的行動。本文特別探討中共中央沒有及時進行 撲滅疫情的原因。

AUTHOR

KA WAI FAN

FAN Ka wai is associate professor at the Chinese Civilization Center, City University of Hong Kong. Dr. Fan earned his PhD (1997) in history from the Chinese University of Hong Kong. He has published extensively (articles, book chapters, encyclopedia entries, and reviews) in the fields of history of Chinese medicine and Internet resource for Chinese medicine. FAN Ka wai est professeur adjoint au Centre de Civilisation Chinoise de l’Université de Hong Kong où il a, en 1997, soutenu sa thèse de doctorat en histoire. Il a abondamment publié (articles, chapitres de livres, entrées d’encyclopédie, recensions) dans les domaines de l’histoire de la médecine chinoise et œuvré à l’accessibilité des ressources électroniques en relation avec la médecine chinoise.

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IV. Regards extérieurs

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Quand la terre s’arrondit. L’horizon convergent des épidémies d’Orient et d’Occident

Anne-Marie Moulin

1 Les éditeurs de cette histoire des épidémies dans l’Asie de l’Est définissaient leur projet en se dérobant à l’idée même d’épidémie, au fond supposée un concept occidental importé, avec sa conjonction d’un comptage des morts et d’une action publique de prévention et de traitement. Aux lecteurs extérieurs, croisant leur regard à celui des auteurs, de trancher si l’on peut parler d’épidémies.

2 Cette histoire des épidémies, par le regroupement de chapitres tous situés dans une même partie du monde, l’Eurasie moins l’Europe, promettait, et tient sa promesse, d’une information passionnante sur des régions mal connues. Elle se situe à la croisée d’une histoire politique avec les particularités et les rythmes propres des états choisis (Corée, Chine, Sibérie, Taiwan et Japon), et de l’histoire des sciences biomédicales, qui obéit à une autre temporalité, celle des découvertes et des innovations.

3 La lecture du numéro spécial sur les épidémies en Asie du Sud, édité par Florence Bretelle-Establet et Frédéric Keck, s’avère bien passionnante, mais sans surprise épistémologique. La lutte contre les épidémies en Extrême-Orient, du XVIIIe siècle à nos jours, semble revêtir des caractéristiques fort proches de celles qui sont familières aux historiens du versant occidental. Les progrès et les innovations de la science bactériologique n’ont pas bouleversé de façon radicale la conduite de la lutte contre les épidémies, elles se sont intégrées par étapes, ce qui a donné le temps à d’autres innovations d’entrer en lice et de relancer le choix des stratégies. Le tempo de l’action et celui de la science diffèrent à l’évidence. La découverte des germes fauteurs d’épidémie au laboratoire a illuminé le raisonnement mais le reste n’a pas forcément suivi, n’en déplaise à Bruno Latour.

4 Les stratégies de lutte contre les épidémies répondent en fait toujours, loin de la science, à des impératifs complexes et persistants, qui incluent des considérations d’opportunité politique, de pressions économiques, le souci de ménager, de séduire ou

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d’intimider des publics. Bref, la science n’apparaît que comme un élément parmi d’autres dans ce que les sociologues appellent la construction d’un problème de santé publique, qui implique celle de sa ou de ses solutions. À moins qu’on ne considère une fois pour toutes, comme l’a fait le strong program dans les années 1980, que la science est intrinsèquement pétrie de politique. Je suis donc partie à la rencontre de quelque chose qui ne s’appelait pas, qui n’était peut-être pas, épidémie.

5 Shin Dongwon décrit l’action publique menée par le roi Jeongjo en Corée dans les années 1786 contre la maladie « rouge », interprétée par l’auteur comme la rougeole. Dans sa politique face aux perturbations, le roi associe des rituels aux dieux tutélaires et aux génies des fléaux. Mais il ne se contente pas de ranimer la ferveur religieuse, il instaure un programme de collecte de recettes utilisées contre la maladie des enfants dans le pays, et décrète la constitution d’un dépôt de remèdes à distribuer à la population.

6 Pour les épidémiologistes contemporains, il y a là clairement une touche de « preparedness », ou d’anticipation de l’événement, qui amène le roi à recenser dans tout le pays les connaisseurs d’un remède efficace. À l’historien de la santé publique en France, un tel programme rappelle celui de la Société Royale de médecine conduite par Vicq d’Azyr avant la Révolution, à peu près à la même période que le roi Jeongjo1.

7 À la lueur de cette comparaison, faut-il voir pour autant dans le roi coréen une figure du despote éclairé ou, au contraire, celle d’un souverain pieux et conformiste, cherchant à restaurer l’ordre menacé par les dérèglements cosmiques en resacralisant les quatre points cardinaux et multipliant les marques de déférence envers la hiérarchie divine et démoniaque ? Y a-t-il lieu d’opposer le modernisme associé à la recherche d’une pharmacopée efficace et à son expérimentation sur le vif devant un mal collectif, et le retour à la tradition, marqué par la relance de rituels confucéens destinés à éviter la colère des dieux et des esprits négligés par les fidèles ? Bref, y a-t-il lieu d’opposer religion et médecine quand tout dispositif face à l’épidémie et à la mort révèle leur durable intrication2 ? L’histoire de la médecine n’est-elle pas tenue à un agnosticisme prudent, lorsqu’elle enregistre les stratégies et les dispositifs de lutte contre les épidémies, évitant de prendre parti et de qualifier de scientifique ou de superstitieux, progressiste ou rétrograde, tel ou tel comportement ? Mais, inversement, n’y a-t-il pas lieu de reconnaître au passage quelque chose qui ressemble à une épidémie et à sa gestion politique ?

8 De même, si la marche du choléra parut étrange au Japon au XIXe siècle, elle semble familière au lecteur occidental. Un avertissement aurait été représenté par une bouffée de mortalité apparue en 1822, après l’accostage d’un bateau américain. Elle fut suivie trente ans plus tard d’une vague de décès coïncidant avec le débarquement du commodore Perry à Nagasaki en 1853.

9 L’épidémie était japonaise et occidentale, par sa coïncidence avec l’ouverture du Japon à l’Occident et son nom l’atteste : le terme japonais pour « épidémie », kurira, vient à l’évidence de « choléra », un terme qui dans beaucoup de langues, y compris l’arabe, dérive du grec médical, de la bile : cholé. Le concept correspond à une philosophie des humeurs qui grosso modo rapproche Orient et Occident et prodigue les mêmes conseils de modération au quotidien, à propos de nourriture, sexe, et alcool, conseils tous destinés à la prévention, l’objectif suprême de la médecine : comme le disait Ibn Sina en son Canon, d’abord conserver la santé avant que d’essayer de la recouvrer. La

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thérapeutique suivait le même cours au Japon que dans les pays d’Europe : opium, réhydratation orale (quand elle est possible !), alcool et petits moyens.

10 La reconnaissance de la nouvelle épidémie, événement inouï à tous les sens du mot, a donc bien introduit le Japon dans le concert des nations et le mainstream des débats sur la contagion, et l’aligne à bien des égards sur eux. L’identification du vibrion en 1883 sera loin de mettre fin au débat et de dire le dernier mot sur le déclenchement et le primum movens des épidémies. L’épidémie se déroule désormais dans un climat de dénonciation de l’Autre, ce qui n’est pas nécessairement contradictoire avec des accusations d’incurie interne, de corruption, ou d’impiété. Elle amène un pays comme le Japon à se positionner à l’égard du reste du monde, entre affirmation de sa supériorité culturelle et reconnaissance inconfortable de sa vulnérabilité aux microbes d’autrui.

11 La même continuité apparaît entre Orient et Occident à propos des pestilences de la Chine, décrites par Florence Bretelle-Establet. Ses régions chaudes avaient une réputation ancienne d’insalubrité et représentaient un exil redouté pour les fonctionnaires impériaux envoyés du Nord. C’est précisément dans l’une de ses provinces, le Guangdong, pendant la peste de 1894, que sera identifiée la bactérie qui porte désormais le nom de Yersin, Yersinia (jadis Pasteurella) pestis.

12 Dans la description médicale des yi et wenyi de la fin du XVIIIe et du XIXe siècles se tisse un frappant parallèle entre le langage occidental des miasmes et la théorie chinoise du qi corrompu, susceptible d’envahir le corps lorsque ses défenses intérieures ont été mises à mal. Face aux pestilences, il est intéressant de noter le jeu original des autorités chinoises : les fonctionnaires essayent de prendre les devants, de ruser avec le calendrier en célébrant des fêtes avant la date prévue pour apaiser les esprits. Mais maladies chaudes ou froides liées aux humeurs du même nom, récurrentes avec les saisons, ou nées de la colère divine et des œuvres perverses des hommes, voilà un cadre plus ou moins familier aux historiens de l’Occident, que la découverte du bacille de la peste ne métamorphosera pas immédiatement.

13 À partir du chapitre sur la santé publique dans la Chine moderne, la cause convergente des épidémies entre Occident et Orient est entendue. Il ne s’agit plus que du modèle d’hygiène à choisir, et c’est ainsi qu’on voit défiler le modèle allemand, le modèle japonais, sommairement caractérisés dans une ambiance de fin du monde autour de la deuxième guerre, dont émerge triomphant le modèle américain, passé de Chine à Taiwan, pendant que le continent s’engage et pour longtemps dans une autre voie.

14 Le sentiment accru de familiarité de l’histoire des épidémies et d’acclimatation du concept coïncide avec une internationalisation croissante de la santé publique, après le trajet en chicane marqué par la colonisation et l’impérialisme. Quelque chose a changé au fur et à mesure des années. À l’ordre sanitaire imposé par les puissances occidentales en Orient a succédé une première tentative d’ordre sanitaire vertueux avec la création de l’OMS en 1947, et son agenda de diplomatie sanitaire. Cette période voit se dessiner une concertation pour l’éradication de la variole, qui implique la collaboration des équipes d’Asie, même si nous ne disposons pas encore (en langue occidentale), contrairement à l’Inde, du récit détaillé de ce qui s’est passé dans les dernières années en Chine, avec l’issue incertaine, presque jusqu’au dernier moment, avant le chant de la victoire3.

15 Les années 1970 marquent le lancement du programme étagé des éradications de la tuberculose, du trachome, de la lèpre, des tréponématoses et, vite en sourdine, du

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paludisme. Cet effort d’éradication signifie une volonté de modification absolue dans le domaine des maladies4, de signature d’un processus irréversible, sans arrière-pensée de conséquences possibles sur le bouleversement des « pathocénoses »5.

16 Puis à « l’ordre relâché6 », de brève durée après l’effondrement du mur de Berlin en 1989, a succédé l’ère de la nouvelle santé globale, avec la mise en place de la « sécurisation » méthodique des maladies, y compris des maladies inconnues, comme le montre Vincent Rollet à propos du SRAS, apparu en 2003 dans le sud de la Chine. Est-ce la dernière fois que les épidémies sont envisagées dans le contexte d’une fièvre obsidionale ou faut-il y voir un échec durable de la pensée en commun ? La sécurisation signifie-t--elle une pacification ?

17 La « sécurisation des maladies infectieuses » a marqué l’inclusion de la menace des maladies infectieuses dans le terrorisme au sens large, un voisinage sémantique dangereux7. La résolution 1308 du Conseil de sécurité des Nations Unies en 2000 a marqué un tournant. Après le 11 septembre, l’OMS a constitué son Comité scientifique sur la sécurité sanitaire globale en 2002. Une diplomatie ad hoc a été lancée simultanément, fondée sur les rapports du National Intelligence Council, un think tank de la CIA, et du National Foreign Intelligence Board, entrainant la mouvance politique américaine, le Canada et l’Australie, et touchant l’Union Européenne et l’ASEAN (Association of South-East Nations).

18 Vincent Rollet propose un modèle à cinq éléments pour le verrouillage sécuritaire autour d’un germe ou d’une maladie, comportant : des entrepreneurs de sécurité, politiques et décideurs ; la rédaction d’une menace bactériologique vitale, par les scientifiques8 ; la désignation d’une cible d’étendue variable ; l’identification de mesures exceptionnelles s’écartant des processus routiniers de veille sur la santé ; enfin, l’acceptation par la communauté d’un tel changement d’attitude.

19 Le passage au global comme nouvel universel ne cache pourtant pas les multiples facteurs déterminant les modalités de la lutte contre les épidémies, apparemment soumise à une sorte de consensus scientifique quasi universel dans le cadre de la sécurisation des maladies contagieuses. Dans le cas de Taiwan, le président Chen en personne a pris l’affaire en main et considéré que la cible du virus n’était rien de moins que l’état taïwanais lui-même, fragile en raison de sa situation stratégique et de son soutien « artificiel » par l’Occident. L’incroyable budget, plus de dix fois celui du Sida, et le déploiement des quarantaines (touchant plus de 100 000 personnes !) illustrent l’intensité de l’effort gouvernemental, s’appuyant sur la police et l’armée. La lutte contre l’épidémie est analogue à un effort de guerre, et le petit nombre de résistances illustre le rôle bien connu, depuis Machiavel au moins, de la guerre, pour faire taire les opposants.

20 La sécurisation de la grippe AH5N1 était une success story dans la mesure où il n’y a pas eu de mort due à ce virus, semble-t-il, et où il est donc loisible aux pouvoirs publics de s’en attribuer le mérite, en arguant des prévisions catastrophiques des CDC (Centers for Disease Control) d’Atlanta, qui prédisaient 15 000 morts à Taiwan. Le désir de certains gouvernements autocratiques de renforcer le contrôle de leur population, ou de prouver leur efficacité et d’accroître leur prestige dans la communauté internationale est sûrement partagé par d’autres pays. L’illustre bien l’exemple du gouvernement égyptien devant la menace de la pandémie grippale, en 2009. Le président Moubarak a saisi l’opportunité de la menace de la grippe aviaire pour accueillir le congrès international interministériel sur la grippe, considérant que par le choix du lieu,

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l’Égypte voyait reconnaître sa contribution à la protection du monde contre l’épidémie et il espérait la monnayer. Le choix du site de Charm al-Cheikh n’était pas un hasard : c’est la zone sécurisée par excellence, elle héberge régulièrement des rencontres diplomatiques.

21 Pour conclure, le nouvel ordre sanitaire, dit global, semble promettre un monde sans coutures, sinon sans frontières, avec consensus sur le concept d’épidémie. La coopération devrait remplacer les mécanismes anciens de défiance et d’exclusion. C’est le sens du grand projet de preparedness, de mobilisation chez soi, pour soi et pour tous, vers lequel convergent tous les pays.

22 Cependant cet état de mobilisation n’est pas décrété pour l’ensemble des maladies, mais seulement pour quelques-unes d’entre elles. Les derniers chapitres invitent donc à une écriture post-globale des épidémies en Asie et ailleurs. La globalité n’est globale qu’en apparence, l’agenda des campagnes de lutte contre les épidémies, y compris les campagnes vaccinales, fait l’objet de préférences discutables des priorités, et il resurgit un paysage changeant et disparate, là où l’harmonie était supposée régner. L’Orient, comme l’Occident, réserve donc des surprises en matière de transformations de la notion d’épidémie et de ses riches connotations, et la rhétorique de la préparation et de la surveillance, succédant à celle des éradications, n’a pas fini de nous étonner par son évolution.

23 Mais finalement s’agit-il au fond du concept d’épidémie, tel que le comprennent les biologistes, et ne s’agit-il pas d’un autre concept, élaboré par une anthropologie historique, qui fait une juste et large part à un imaginaire, probablement partagé de l’Extrême-Orient à l’Extrême-Occident ?

24 Les récits historiques d’Orient et d’Occident sur ce qui ressemble à des épidémies partagent les projections et les mécanismes par lesquels sont désignés les responsables et les coupables : le voyageur, le nomade, le migrant, le pélerin. Les uns et les autres jouent un grand rôle dans l’imaginaire des maladies de groupes, associées à des fantasmes de rapt, de viol et de violence. Le nomadisme a toujours enflammé l’imagination. Il a d’ailleurs créé une esthétique qui lui est propre, privilégiant la courbe, les lignes de fuite, les mélodies aux interminables reprises. Il y a un lien entre les terriers des marmottes que Matignon, le médecin mis en scène par Christos Lynteris, tient pour réservoirs de la peste, où les animaux entrent en diapause pendant le long hiver sibérien, et les kourgans des steppes, ces monticules correspondant aux tombes où les guerriers dorment leur dernier sommeil, prêts à resurgir les armes à la main9.

25 Le terme de pèlerinage vient spontanément à propos de l’épidémie de méningite en Chine contée par Fan Ka wai. Il y a bien eu pèlerinage en 1966, mais pas auprès du tombeau d’un saint, d’un fondateur de confrérie, ni d’un compagnon du Prophète, à la Mecque, ni à Kerbela en Irak, ni à Touba au Sénégal. Il s’adressait à un dieu bien vivant, le président Mao, appelant à ses côtés les Gardes Rouges venus de l’ensemble du pays pour propager la révolte contre les Traditions.

26 Fan Ka wai suggère que Mao a déclenché ce mouvement pour désarmer les critiques et déplacer l’équilibre politique en sa faveur. Les mauvaises conditions du transport en commun de millions de jeunes, jointes aux rigueurs de l’hiver, auraient permis au méningocoque de se disséminer dans tout le pays, quand l’ordre leur fut donné de se déplacer à pied, au printemps 1967. Mao a toléré l’épidémie, peut-être n’a-t-il pas compris son mécanisme. Il s’agit là presque d’une fable morale, dévoilant les

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cheminements du germe dans les déplacements en masse des Gardes Rouges. Mais est- ce le dernier sursaut d’une histoire forclose, et l’épidémiologie moderne va-t-elle annuler les calculs d’intérêt des différents pouvoirs en présence et en compétition ? La fable politique de l’épidémie de méningite de 1966-1967 ne fait-elle pas au contraire préjuger des difficultés futures d’un ordre sanitaire truqué ?

27 La Chine et, de façon plus générale, les pays de l’Extrême-Orient sont aujourd’hui partie prenante dans les Grands jeux et les Olympiades de la politique et de l’économie. La santé peut apparaître comme le versant sympathique et efficace d’une mondialisation dont les conséquences à court et long terme ailleurs déconcertent, inquiètent et parfois scandalisent. À « l’ordre relâché10 » a succédé un nouvel ordre sanitaire caractérisé par un souci de sécurité amarrant le domaine sanitaire au politique. Dans un monde qui tend à se réunifier autour des objectifs de l’horizon 2020 et au-delà, les épidémies obéissent à un nouvel ordre qui n’est pas dicté par les seuls calculs de morbidité et de mortalité : pour certaines épidémies comme la grippe, la preparedness mondiale est orchestrée, soutenue, évaluée, et financée. D’autres épidémies n’intéressent personne, comme la maladie du sommeil, ou pas grand monde, comme la méningite ou les hépatites B. Où est donc la gouvernance tant vantée ? L’imaginaire des épidémies comporte lui aussi ses leçons en sensibilisant à une certaine continuité dans le temps comme dans l’espace, et tel est l’apport remarquable de cette œuvre commune d’anthropologie historique.

BIBLIOGRAPHIE

CHUVIN Pierre (dir.) (1999). Les Arts de l’Asie centrale. Paris, Citadelles et Mazenod.

DERENNE Jean-François et BRICAIRE François (2005). Pandémie. La grande menace. Grippe aviaire, 500 000 morts en France ? Paris, Fayard.

DESAIVE Jean-Paul, GOUBERT Jean-Pierre, LE ROY LADURIE Emmanuel, MEYER Jean, MULLER Otto & PETER Jean-Pierre (1972). Médecins, climats et épidémies à la fin du XVIIIe siècle. Paris, EHESS.

FENNER Frank et al. (1988). Smallpox and its Eradication. Genève, World Health Organization.

LAIDI Zaki (1993) (dir.) L’Ordremondial relâché : sens et puissance après la guerre froide. Paris, Presses de la Fondation mondiale pour les sciences politiques.

MOULIN Anne-Marie (2004). « L’Éradication des maladies, remède à la globalisation ? » In Yves Michaud (dir.), Qu’est-ce que la globalisation ? Paris, Odile Jacob : 207-228.

MOULIN Anne-Marie (2007). « Prédiction, prévention, précaution. Perspectives historiques et épistémologiques ». In Ilario Rossi (dir.), Prévenir et prédire la maladie. De la divination au pronostic. Paris, Aux Lieux d’Être : 103-119.

WINSLOW Charles-Edward Amory (1980). The Conquest of Epidemic Disease. A Chapter in the History of Ideas. Madison, University of Wisconsin Press.

SCHILTZ Véronique (1994). Les Scythes et les nomades des steppes. Paris, Gallimard.

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NOTES

1. Desaive, Goubert, Le Roy Ladurie, Meyer, Muller et Peter 1972. 2. Moulin 2007. 3. Fenner et al. 1988. 4. Moulin 2004. 5. De l’idée proposée par Mirko Grmek de la nécessité de tenir compte de l’ensemble des pathologies (écologie), on est passé à l’idée que la modification d’un élément du système ainsi constitué pouvait avoir des conséquences imprévisibles sur le développement ou même l’émergence de nouveaux agents pathogènes. L’arrivée du VIH a fortifié cette approche. 6. Laidi 1993. 7. Winslow 1980. 8. Derenne et Bricaire 2005. Un best-seller, même si sa prophétie n’a (heureusement) pas été suivie d’effet. 9. Schiltz 1994 et Chuvin 1999. 10. Laidi 1993.

AUTEUR

ANNE-MARIE MOULIN

ANNE-MARIE MOULIN, ancienne élève de l’École normale supérieure, médecin et agrégée de philosophie, est directeur de recherche émérite dans l’unité SPHERE (UMR 7219, CNRS/ Université Paris-Diderot). Elle a mené de front une carrière en médecine tropicale et en histoire des sciences, en France et à l’étranger, en particulier aux États-Unis et dans le monde arabe. Elle a notamment publié Le Dernier Langage de la médecine (1982), L’Aventure de la vaccination (1996), Le Médecin du Prince (2010), Le Labyrinthe du corps. Islam et révolutions scientifiques (2013) et, en collaboration, L’Islam au péril des femmes (2001), Science and Empires (1992), Singular Selves (2001). Anne-Marie Moulin est membre du Haut conseil de la santé publique. Anne-Marie MOULIN, student from the École Normale Supérieure, physician and holder of an agrégation in philosophy, is emeritus director of research at SPHERE (UMR 7219, CNRS/ Université Paris-Diderot). She is member of the French Haut conseil de la santé publique. She managed at once a medical career in tropical medicine and in history of medicine, in France and in other countries, notably in the United States and in the Arab world. She has notably published Le Dernier Langage de la médecine (1982), L’Aventure de la vaccination (1996) and, in collaboration, L’Islam au péril des femmes (2001), Science and Empires (1992), Singular Selves (2001), Le Médecin du Prince (2010), Le Labyrinthe du corps. Islam et révolutions scientifiques (2013).

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Le retour des dispositifs de protection anciens dans la gestion politique des épidémies

Patrice Bourdelais

1 La lecture des textes rassemblés ici conduit tout d’abord au plaisir de la découverte de nouveaux aspects et résultats de la recherche sur des pays, époques et situations qui demeurent, quoi que l’on fasse, quelque peu lointains dans notre culture d’historien des épidémies et de la santé publique dans les pays d’Europe de l’Ouest. Chemin faisant dans le dossier, les rapprochements avec des situations européennes viennent à l’esprit, qu’il s’agisse de l’intervention forte du pouvoir royal coréen dans la deuxième moitié du XVIIIe siècle afin de maîtriser une épidémie de rougeole très agressive, de la découverte épidémiologique qui inverse les termes de la responsabilité dans la progression de la peste ou bien encore des liens qui unissent la révolution culturelle chinoise et une épidémie de méningite cérébro-spinale.

2 On peut y observer, comme dans l’Europe de l’Ouest, l’évolution de l’organisation de la lutte contre les épidémies par les États, qui peut être lue à la lumière des concepts de biopolitique et de gouvernementalité de Michel Foucault. L’exemple de la mise en place de mesures très contraignantes et précises par le roi Jeongjo en Corée offre une illustration de l’intervention de la Couronne afin de protéger et de faire fructifier la population et de renforcer les structures idéologiques traditionnelles de l’État. Celui de la dynamique entre la Révolution culturelle chinoise et l’épidémie de méningite cérébro-spinale met en scène les différentes phases de conciliation entre des gouvernementalités différentes : la raison d’État, dominante, et la santé publique, secondaire certes pendant quelques mois mais dont le caractère indispensable est intégré ensuite très rapidement à la raison d’État.

3 Chaque contribution à ce volume suscite la comparaison avec d’autres époques, d’autres épidémies et d’autres situations. Mais je m’arrêterai volontiers sur le cas de Taiwan qui est ici l’objet de deux articles assez complémentaires. Celui de Vincent Rollet analyse le lien entre la gestion des épidémies et l’approche sécuritaire qui s’est particulièrement manifestée lors de la gestion de l’épidémie de SRAS et de H5N1 en

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2003-2005. À partir des travaux de Barry Buzan et al. (1998) et de la contribution de Sara Davies « Securitizing Infectious disease » (2008), il examine le processus par lequel ces maladies sont devenues des questions de sécurité nationale à Taiwan, en mettant l’accent sur les initiateurs de cette dynamique, leurs discours puis la façon dont se concrétise une telle approche. Les autorités taiwanaises ont décidé de considérer la présence du SRAS puis du H5N1 comme des questions de sécurité nationale qui se traduisent par une succession de mesures. Dès le lendemain de l’annonce du premier cas de SRAS, le Président de Taiwan déclare que la lutte contre la nouvelle épidémie a la même urgence que la défense de la sécurité nationale en général. Ce sont les citoyens et la stabilité économique du pays qui constituent l’objectif principal des mesures prises, y compris celles qui doivent éviter les comportements paniques. Cette initiative est considérée comme sans précédent. Bien entendu, un budget spécifique et très important est voté, il dépasse de beaucoup celui consacré à la lutte contre le VIH/Sida. Une quarantaine est organisée pour toute personne ayant été en contact avec un malade afin de prévenir une extension de la contagion. L’isolement était néanmoins plus ou moins strict, allant de l’enfermement complet à la possibilité de quitter la quarantaine pour acheter par exemple ses repas. Les personnes qui ne se soumettent pas aux règles de la quarantaine encourent aussi bien des amendes élevées (286 personnes concernées) que des peines de prison. Plus d’un millier de soldats sont aussi mobilisés, dont certains chargés d’opérations de désinfection. Le choix d’un hôpital militaire afin d’accueillir et de traiter les malades, ainsi que les communiqués quotidiens des autorités sanitaires, ne peuvent que renforcer le sentiment que l’on mène une véritable guerre contre l’ennemi.

4 Lorsque l’épidémie de H5N1 menace, fin 2005, l’État réagit de la même manière (réunion du haut conseil de sécurité nationale, vote d’un budget spécifique élevé). La présence de volailles vivantes sur les marchés est interdite. Taiwan envisage de produire, à des fins d’usage domestique, du Tamiflu, avant d’avoir reçu l’autorisation des laboratoires Roche, ce qui correspond à une décision exceptionnelle qui n’est finalement pas mise en exécution car le H5N1 ne se manifeste pas sur l’île.

5 Le caractère spectaculaire des mesures prises, en particulier la mise en place de quarantaines, lors du SRAS paraît avoir frappé les esprits des contemporains par leur nouveauté. Il suffit pourtant de retourner cinquante ans en arrière pour constater la banalité de ce dispositif à Taiwan même. Dans les conditions épidémiologiques de sortie de la Seconde Guerre mondiale, face à la multiplication des cas de malaria mais aussi de peste et de choléra, on retrouve alors ce qui avait constitué la base des dispositifs de protection des épidémies depuis six siècles au moins. Avec le retour de Taiwan à la Chine en 1945, les épidémies importées du continent se multiplient : en particulier peste, choléra, variole et une recrudescence de la malaria. C’est alors que sont mis en place des contrôles (épaulés par des examens de laboratoires) et quarantaines dans les ports taiwanais afin d’éviter les importations de Chine continentale. Les contrôles sont à nouveau renforcés en 1947 (afin de répondre au niveau d’exigence international des dispositifs de quarantaines) si bien que toute importation d’épidémie de Chine continentale est évitée au cours de l’année suivante. À partir de 1949, l’aide médicale et sanitaire américaine se retire de Chine continentale et se concentre sur Taiwan, contribuant en peu d’années à réduire la malaria et à supprimer la peste, le choléra et la variole. La mémoire de cette période aurait-elle disparu de Taiwan au début des années 2000 ?

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6 Pour les historiens de la longue durée, le grand virage de la fin du XXe siècle, du côté des organisations, est lié au constat d’un échec : en dépit des progrès de la science et de la hausse du niveau de vie, les épidémies, strictement nouvelles ou ré-émergentes, deviennent à nouveau des dangers pour chaque pays ainsi que pour la prospérité et la stabilité mondiales. Dans son article, Michael Shiyung Liu cite deux travaux qui concluent à l’efficacité forte des quarantaines mises en place à la sortie de la guerre. Vincent Rollet cite lui aussi une estimation de la réduction de la contagion et du nombre de décès réalisée grâce aux mesures de confinement et de quarantaine lors de l’épidémie de SRAS. Pourquoi s’étonner de tels succès ? Comment expliquerait-on, si la quarantaine n’était pas efficace, qu’elle ait été une pratique systématique en Europe et au-delà du milieu du XIVe au milieu du XIXe siècle (Bourdelais 2003) ? L’historiographie s’est souvent complue à souligner les failles de tout système coercitif, mais l’irruption de la peste n’a été qu’exceptionnelle par rapport aux risques que les ports d’Europe occidentale encouraient chaque année. Dans plusieurs cas bien documentés, le dispositif de cordons sanitaires et de quarantaines a permis de sauver des régions entières de l’épidémie (je pense à l’arrêt de la peste du début du règne de Louis XIV stoppée par le cordon protecteur tendu entre Rouen et Reims afin de sauver la Capitale, puis à la Peste de Marseille qui, en 1720-1722, ne réussit guère à sortir de la Provence et d’une partie du Languedoc). Lorsque les États ont délibérément organisé des cordons sanitaires et des quarantaines, les épidémies ont la plupart du temps été stoppées. Mais ces dispositifs avaient un coût élevé. Économique tout d’abord, car non seulement ils interrompaient les relations commerciales pendant des mois, voire des années, mais ils nécessitaient le maintien sous les armes de dizaines de milliers de soldats. Politique ensuite, car ils entravaient la libre circulation des individus qui, lorsqu’ils tentaient de traverser les lignes, risquaient d’être abattus par un soldat (Baldwin 1999).

7 La conciliation entre les contraintes liées au maintien de la santé publique et la liberté individuelle fut toujours un sujet délicat, au point que le cordon sanitaire et la quarantaine furent au XIXe siècle synonymes de régimes totalitaires. L’Angleterre libérale proposa alors un nouveau régime de protection, fondé sur l’examen médical à l’arrivée des bateaux, l’hospitalisation des malades dans des hôpitaux dédiés et le suivi pendant quelques semaines des passagers qui paraissaient bien portants. C’est à cette époque que la responsabilité individuelle du malade qui fréquentait des lieux ou des transports publics fut engagée ; elle pouvait le conduire à devoir payer une amende ou à effectuer quelques jours de prison. Mais il ne faut pas oublier qu’au XIXe siècle, et parce que la plupart des épidémies suivaient l’itinéraire des cargos de l’est vers l’ouest de la Méditerranée, l’Angleterre avait réussi à sécuriser le bassin occidental en contrôlant les passages à Malte puis à Gibraltar. Il devenait alors moins risqué de lever les dispositifs contraignants à l’entrée en Angleterre ! Les Commissions internationales sanitaires furent chargées, jusque dans les années 1930, de continuer à protéger l’Europe de l’Ouest des épidémies en déplaçant la charge du contrôle à Istanbul et Alexandrie (Roemer 1994).

8 C’est précisément ce qui n’est plus possible depuis les années 1980 du fait de la globalisation qui s’amplifie régulièrement : toujours plus d’avions, emmenant toujours plus de voyageurs directement d’un point du globe à un autre, y compris dans des régions reculées ou récemment ouvertes au contact. Cette mobilité sans précédent ne permet plus aucun contrôle réel. Il s’agit de la principale raison de l’inquiétude des milieux sanitaires internationaux qui scrutent avec vigilance – il s’agit bien de leur

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fonction – l’émergence d’une nouvelle épidémie toujours possible et, devrait-on dire, attendue. Tous les gouvernants du monde savent à quel point une épidémie grave peut déstabiliser profondément leur société ; cela explique bien, aussi, le virage des années 1990-2000.

9 L’horizon historique d’éradication des maladies infectieuses, que les pays développés pensaient pouvoir un jour atteindre, s’est éloigné (Cockburn 1963). Les nouvelles découvertes sur les logiques du vivant ont montré qu’il est vain de préparer des vaccins antiviraux trop à l’avance. La globalisation, la faiblesse des antiviraux disponibles et les résistances de plus en plus nombreuses aux antibiotiques convainquent de la grande fragilité de notre système de santé globale actuel. Pour les épidémiologistes, toutes les variables présentent des valeurs qui doivent conduire à la catastrophe que l’on attend, avec crainte, mais aussi avec un soupçon d’intérêt car il sera alors temps de passer à l’action, de mettre en place tous les plans qui ont été préparés (parfois répétés) depuis des années. De ce fait, une tendance à la surestimation du risque est aujourd’hui probablement présente dans la majorité des milieux responsables du contrôle de la santé publique internationale.

10 Mais la tonalité actuelle des travaux qui parlent de sécurisation des maladies infectieuses laisse penser que leurs auteurs ont oublié qu’il ne s’agit en rien d’une nouveauté (mis à part le rôle nouveau de l’OMS qui accentue, avec de nouveaux moyens, le rôle tenu pendant longtemps par les Conférences sanitaires internationales) mais simplement du retour à une attitude de très longue durée des États qui se défendent tout autant contre les grands dangers épidémiques que contre le voisin hostile. Souvent d’ailleurs, la contagion vient bien de l’étranger, comme l’ennemi. La contribution de William Johnston sur les réactions face aux premières épidémies de choléra au Japon au XIXe siècle le montre. A contrario, le mouvement hygiéniste, qui prend son essor dans les pays d’Europe occidentale au XVIIIe et s’exprime complètement au XIXe siècle, consiste à rompre avec cette tradition et à considérer que la maladie ne vient pas de l’étranger mais qu’elle est bien présente au cœur des villes et des villages, liée aux conditions de salubrité très insuffisantes pour assurer un environnement qui ne soit pas propice à la multiplication des maladies sur place. Cette inversion de conception conduit à faire circuler l’air afin qu’il ne stagne pas (dans les logements et les immeubles par exemple) et elle aboutit au modèle anglais du lavage permanent de la ville qui doit recevoir beaucoup d’eau afin qu’elle en draine les effluents vers la rivière voisine. Cette grande circulation hydrique a constitué le modèle de référence de l’hygiène publique moderne, elle supposait l’adduction d’eau courante et la construction de réseaux d’égouts (Hamlin 1998). À partir du moment où le choléra devient endémique au Japon, les conditions d’une prise en charge de l’organisation de la salubrité sont d’ailleurs réunies. Mais cette lecture comparée ne peut se faire qu’en creux car l’axe des travaux présentés ici ne concerne pas les transferts sanitaires de l’Occident vers l’Orient sauf en ce qui concerne la Chine des années 1930 et les grands acteurs de l’influence médicale américaine. Finalement, les effets des oppositions politiques, voire guerrières, entre Chine du Nord et Chine du Sud, entre Japon, Chine et Corée, entre Japon, Chine et Taiwan sur les représentations sanitaires et sur les politiques de protection contre les épidémies, y sont très présents. C’est une dimension qui paraît, du fait des contributions rassemblées ici, plus discriminante qu’en Europe.

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BIBLIOGRAPHIE

BALDWIN Peter (1999). Contagion and the State in Europe, 1830-1930. Cambridge, Cambridge University Press.

BOURDELAIS Patrice (2003). Les Épidémies terrassées. Une histoire de pays riches. Paris, Éditions de La Martinière.

BUZAN, BARRY, WAEVER Ole, DE WILDE Jaap (1998). Security: A New Framework for Analysis. Londres, Lynne Rienner Publishers.

COCKBURN Aidan (1963). The Evolution and Eradication of Infectious Diseases. Baltimore, Johns Hopkins Press.

DAVIES Sara (2008). « Securizing Infectious Disease ». International Affairs, vol. 84, 2: 296-313 (Wiley Online Library).

HAMLIN Christopher (1998). Public Health and Social Justice in the Age of Chadwick: Britain, 1800-1854. Cambridge, Cambridge University Press.

ROEMER Milton (1994). « Internationalism in Medicine and Public Health ». In Dorothy Porter, The History of Public Health and the Modern State. Amsterdam/Altanta, Rodopi : 403-423.

AUTEUR

PATRICE BOURDELAIS

Patrice BOURDELAIS est directeur de recherche à l’EHESS et dirige la section des Sciences Humaines et Sociales (INSHS) du CNRS. Historien et démographe, il a travaillé sur l’histoire de la santé publique en France dans les deux derniers siècles. Il a notamment publié Une peur bleue. Histoire du choléra en France (1987), L’Âge de la vieillesse. Histoire du vieillissement de la population (1993), Epidemics Laid Low. A History of What Happened in Rich Countries (2006). Il a dirigé Les Hygiénistes. Enjeux, modèles et pratiques (XVIIIe-XXe siècles) (2001) et, avec Didier Fassin, Les Constructions de l’intolérable (2005), ainsi que, avec John Chircop, Vulnerability, Social Inequality and Health (2010). Patrice BOURDELAIS is directeur d’études at the EHESS and heads the Division of social sciences and humanities (INSHS) of the CNRS. As a historian and demographer, he has worked on public health in France in the last two centuries. He has notably published Une peur bleue. Histoire du choléra en France (1987), L’Âge de la vieillesse. Histoire du vieillissement de la population (1993), Epidemics Laid Low. A History of What Happened in Rich Countries (2006). He edited Les Hygiénistes. Enjeux, modèles et pratiques (XVIIIe-XXe siècles) (2001) and, with Didier Fassin, Les Constructions de l’intolérable (2005), still, with John Chircop, Vulnerability, Social Inequality and Health (2010).

Extrême-Orient Extrême-Occident, 37 | 2014