In 1869, Dr. Alexander R. Jamieson, a medical officer of Shanghai Customs Station, suggested to Sir Robert Hart (1834–1911), the inspector-general of Chinese Imperial Customs, that the customs establishment should take advantage of its unique position to collect information about the diseases of foreigners and natives in China. Hart then issued a circular on December 31, 1870, to the commissioners of customs at all treaty ports, in which he invited the medical officers and medical missionaries of the various ports to investigate the general health and disease prevalence at their ports for the observation of local peculiarities of diseases, especially those diseases that were rarely or never encountered anywhere outside of China. Hart reasoned: “If carried out to the extent hoped for, the scheme may prove highly useful to the medical profession both in China and at home, and to the public generally.” On September 11, 1871, the first issue of the Medical Reports was published in Shanghai at Hart's order, which was the first of eighty volumes published over the next forty years with hundreds of reports from China, Hong Kong, and Korea as well as Japan. They provided an abundance of data that offers historians a largely untapped resource for research on medicine and public health in nineteenth-century China and Asia. By presenting the scope of the Medical Reports, this chapter demonstrates that research activities related to the biomedical discovery of diseases began in nineteenth-century China and Asia and should be considered a significant episode in the narrative of the spread of Western medicine. In particular, it demonstrates the role of medical officers of the Maritime Customs Service and medical missionaries in promoting the globalization of scientific medical knowledge by establishing a standard of classification for investigating epidemic diseases not only in China and Asia more generally, but also in Europe and Africa.

The present chapter will explore why the customs service was organized and why it issued medical reports, in addition to the relationship between these; and also how foreign medical officers and medical missionaries discovered and identified the diseases that they had never encountered anywhere else.

Dr. Chen Zhiqian, China's “father of public health,” is consistently celebrated for the five and a half years he spent as director of the Department of Health in north China's model county in Hebei, Dingxian Province. Dr. Chen (also known by the Anglicized name of C. C. Chen) directed public health work in this chief site of the Rural Reconstruction Movement from January 1932 to July 1937. However, he left another important and lasting legacy in his home province of Sichuan during the Second Sino-Japanese War (1937–45), work for which he is seldom recognized. For six years during the war, from May 1939 to November 1945, Chen Zhiqian served as director of the Sichuan Provincial Health Administration (Sichuan sheng weishengchu), or SPHA, in the southwestern province that boasted the wartime capital of Chongqing. Founded in spring 1939 and headquartered in Chen's hometown of Chengdu, the provincial capital, the SPHA established county health centers (xian weishengyuan), or CHCs, in 131 of the province's 139 counties before the war ended in 1945, and continued to operate through 1948. The bulk of this work built on and greatly expanded the Dingxian legacy. Taken as a whole, Chen's Rural Reconstruction work in prewar northern China and his wartime work in Sichuan laid the foundations for the expansion of public health services into rural China in the Communist period.

The work of the SPHA also played a key role in two wartime processes of enormous importance to the nation. First, the establishment of a county health center in all but eight of Sichuan's counties was a chief means by which the once independently ruled province was incorporated into the nation. Doctors, nurses, midwives, and public health personnel who had worked to establish state-administered public health services in other parts of China prior to the war transferred their talents to Sichuan during the war, building a health infrastructure in the once remote province that mirrored that of communities in northern and eastern China. Since public health administration constituted an important part of state formation and nation building, this work did more than treat individual bodies; it constructed Sichuan as part of the national body. Second, CHC staff actively promoted scientific biomedicine in semiurban and rural towns throughout Sichuan.

Dr. Tang Erhe (1878–1940) could not keep silent at the meeting of the National Education Assembly in Beijing late in 1912 when he heard that the top educational priority of the new Republic of China was to establish more schools of politics and law. China would not save itself from the forces that threatened it merely by training politicians, lawyers, and diplomats, Tang argued—science was needed to save the nation, and science could only be established by building institutions for training and research.

Tang had recently graduated from Kanazawa Medical Technical College (Kanazawa igaku senmon gakkō) in Japan and returned to his native Hangzhou to set up a modern hospital and medical school while also becoming drawn into the provincial and national politics of the Xinhai Revolution. The revolutionary medical doctor, Sun Yat-sen, became the Republic’s first president, while Tang Erhe filled in as speaker of the provisional national assembly that elected Sun. When people took note of how remarkable it was that two modern-style physicians played prominent roles in the provisional Republican government, a saying became popular that remarked on the singularity that both the speaker of the assembly and the president of the Republic were both physicians. China had become known as “the Sick Man of East Asia” (dongya bingfu), but neither physician seemed able to implement his prescription to save China. Sun Yat-sen was forced to resign within six weeks in favor of strongman Yuan Shikai, while Tang resigned as speaker and returned to his medical work in Hangzhou. Medical science itself was a form of politics for Tang Erhe, and the reproduction of like-minded professionals combined with establishment of institutions of scientific research was his solution to China’s failed revolution. But when asked to become an offi-cial adviser to the Ministry of Education, and soon thereafter to start a central government–administered medical school in the capital, Tang accepted and left for Beijing.

On a summer day at twilight in 2009, I sat with William Schneider at a coffee shop in Budapest during the Twenty-third International Congress of History of Science, Technology, and Medicine discussing the state of historical research on the global spread and exchange of modern medical technology. We agreed that there remains much work to do researching the history of medicine in modern China, and especially that there are many primary sources, hospital reports, and medical journals that have not been fully explored and utilized. Beginning in the mid-nineteenth century, medical missionaries practiced Western medicine in China and became important disseminators and practitioners. In the process, they left behind plentiful historical documentary sources—correspondence, diaries, and official reports—scattered in the libraries and archives of, among others, Chinese, American, British, and Canadian churches, universities, and hospitals. All of these, we agreed, should be systematically organized and completely researched, so we proposed collaborating to apply for a research grant that would address these lacunae.

On the strength of Bill Schneider’s great efforts, the grant proposal gained the active support of the Luce Foundation, which first agreed to support preliminary research in order to prepare for the formal beginning of the project. On October 28–29, 2010, Peking University Medical History Center and Indiana University Philanthropy Center held an academic discussion conference called “Western Medicine and Philanthropy in China: History and Archive.” Schneider and I each introduced a tentative overall plan and important research content for the project, while Martha Smalley introduced archival documents from Yale University Divinity School’s library and archives collections about the missionary medical schools and universities in China; Xu Jinhua introduced the collections at the Shanghai Xujiahui Library that included documents on foreign medicine; Dang Yuewu introduced an outline of the complete collections of West China Union University Medical School, located at Sichuan University Archives; Zhang Xia and an American representative of the Chinese Medical Board introduced Peking Union Medical College and its associated records at the Rockefeller Archive Center; and Peng Jianping presented on the condition of collections at Sun Yat-sen University Medical School’s Historical Archives. In addition, conference attendees presented reports on Suzhou’s Boxi Hospital, Beihai’s Pokhai (Puren) Hospital, Guilin’s Daosheng Hospital, and the early history and archives of several other Christian hospitals.

China's post-Mao embrace of market socialism has transformed its society over the past forty years, and modernization has become the prime directive in almost every realm of life. Yet in this headlong embrace of modernity, there is little space for a healthy critique of the processes and unintended consequences of modernization. Modernity has arguably offered increased wealth and comfort for millions in China, but the increased convenience of life has not necessarily led to an increased quality of life—we need only look to the dramatic health effects of pollution on all residents in cities like Beijing as an example. Interestingly, this headlong turn to praise modernization has led to a reevaluation of China's semicolonial past. While the twentieth century largely saw the historical disparagement of foreign missionaries and other foreign physicians as agents of imperialism, the turn toward modernization as the goal (rather than the means to an egalitarian socialist society) has resulted in most Chinese-language accounts today praising the contributions of medical missionaries and other foreign builders of public health systems. This, despite the complicated impact of such systems on the lives of Chinese people of all classes and their arrival under the unequal conditions of foreign imperialism. Yet our histories of public health must not merely be paeans of praise to the pioneers of public health; they must also recognize the sacrifices that these measures forced on ordinary people. Although something was gained by increased hygiene, much was also lost. This chapter is a reflection on the empirical findings in my recent book, Qingdai weisheng fangyi jizhi jiqi jindai yanbian (Qing-era hygienic prevention mechanisms and their modern transformation), where I elaborate on the issues of quarantine and the management of water and night soil in the rapidly growing urban centers at the end of the Qing dynasty. For all that was gained in disease management, whole economies and livelihoods were disrupted, while personal freedoms were severely restricted.

In the late nineteenth and early twentieth centuries, Western conceptions of health and hygiene that were designed primarily to avoid the spread of epidemic disease by ship or train gradually began to infiltrate port cities of China where unequal treaties allowed foreigners to trade, reside, and establish local settler governments.

This volume studies China-based biomedical work and its contribution to the common knowledge and practice of global biomedicine before the 1949 Communist Revolution. The basic contention of this book is that China was not merely a destination for biomedical knowledge and practice from elsewhere but was a fundamental site in the creation of biomedicine. In 1939, the prominent American pathologist Eugene L. Opie wrote the introduction for a special issue of the Chinese Medical Journal arguing that medical science produced in China and published in the issue demonstrated that Chinese physicians trained in the methods of Western medical science were addressing both “conditions particular to China” and also “fundamental problems of pathology and clinical medicine.” This book takes a much wider scope to examine the impact biomedicine had on Chinese society and the impact Chinese society had on biomedicine. It demonstrates that Chinese and foreign physicians based in China pursued research and practiced medicine relevant to China's particularities and also basic to experimental and clinical medicine around the world. China was unique because of the enormous scale of the problems of disease and medical delivery encountered by those who sought to establish a medical system as part of a modern state.

By the 1930s and 1940s, China's attempts to provide preventive and curative medical care for its citizens became an issue of international interest and a key policy problem for Chinese medical reformers like Robert K. Lim (Lin Kecheng) and C. C. Chen (Chen Zhiqian), encouraged by international observers who suggested that China might be a model for the world if it could bring health care to its people at a cost that could be borne through modest per capita government expenditures. As Henry S. Houghton of the Rockefeller Foundation put it, “If the Chinese Government can solve the problem of adjusting competent medical and nursing care to a sum total so that society can afford to pay, it will earn the grateful praise of a troubled world.” Certainly China took advantage of medical ideas and practices produced elsewhere, but it was also a laboratory for a new kind of state-based social medicine established to serve the people and not just the interests of physicians.

Metamorphosis, the patriotic play written by Cao Yu in 1940 after the outbreak of the Second Sino-Japanese War, depicts the wartime transformations of a decadent hospital in the context of Japanese aggression. While revealing the Chinese bureaucracy's inefficiency and corruption, Cao Yu portrays how the Chinese medical profession changed during wartime. In the play, a group of nurses work at gunpoint with a doctor to serve civilians, soldiers, and the national cause. The nursing staff, a man and two women, are dressed indistinguishably in white uniforms—“a gown of the bottom-up design, with the logo of a red cross embroidered on the left arm and a white cap on the head”—and working with “white gauze and white utensils.”

This dramatic portrait of medical workers was based on China's actual wartime realities, and it raises a series of historical questions about how gender and power relations affected the professionalization of wartime nursing. Given that white is associated with death and funerals in Chinese culture, why would nursing pioneers in China insist that these agents of healing wear white uniforms? More importantly, how did the war shape the experience of nurses? The prominence of nurses in this play is remarkable given the fact that foreign missionary nurses had only introduced the profession into China a few decades earlier. Before the rise of nursing, relatives and servants within the family held the primary responsibility of caring for the sick; a trained person to take care of the sick would strike Chinese as an alien concept. Confucian ethics stressed that respectable women should remain in the home, so a profession of attending strangers including men other than their husbands was “a breath-taking innovation.” During the 1910s, when the American nurse Nina Gage launched a pioneering nursing school in Hunan, she found it necessary to coin a Chinese term for “nurse.” Gage and her colleagues selected hushi, which might be translated as “guard scholars.” In contrast to nursing as a “women's profession” in the Anglo-American world during the early twentieth century, the enrollment of nursing students in China did not start as gender-exclusive. In fact, for Gage, boys seemed to be more promising nursing students, as “too many problems complicated the lives of the girls.”

In 1934, two of China's largest nationwide medical organizations, the Chinese Medical Association (CMA) and the China Medical and Pharmaceutical Association (CMPA), tried to amalgamate, but then failed, due to a series of impolitic articles in the Chinese section of the Chinese Medical Journal in 1933. This chapter will examine this incident, revealing the underlying reasons in order to emphasize that the development of modern medicine in Republican China was seriously impeded by the contradictions between multiple groups of Western-style doctors. The appearance of these distinct groups of physicians can be attributed not only to the impact of different colonial powers on China, but also to the different experiences of development and group interests that led these different groups to diverge from each other. When the contradiction between modern Western-style medicine and Chinese native medicine intensified after 1929, the relationship between these groups of Western-style doctors worsened, and as a result, Western-style doctors failed to merge or even find agreement on many issues to improve the state of Western-style medicine in China.

In the past few decades significant research has been done on medicine in Republican China, particularly the massive transformation of Chinese medicine. As a variation of the impact-response model, many studies emphasized Chinese native doctors’ resistance or adjustment to the transformation. Comparatively less attention has been paid to Western-style doctors, especially as groups or associations, due perhaps to the influence of China-centered history since the 1980s. Some scholars have pointed out the different opinions among Western-style physicians on the issues of abolishing Chinese native medicine and building a modern style of medicine. Memoirs of various physicians have also mentioned that there were different factions among Western-style doctors; they had conflicts in either the bureaucracy or various medical institutions. However, some basic questions have not yet been answered: When and how were these groups formed? What were the differences among them? How did these differences affect their nature? Understanding the nature of Western-style doctors is essential for us to understand medicine in Republican China; they were, after all, primary advocates and promoters in the development of modern medicine in China. In this chapter, I will explore the divergence between two leading Western-style doctors’ associations by focusing on the failed merger incident in 1934, and then discuss the reason behind this divergence and the influence it had on the medical field.

A main goal of this volume has been to show how China-based developments in Western medicine incorporated China as an integral site in the creation of global biomedicine. Beginning in the nineteenth century, Western Europe developed an approach to medicine based on new scientific discoveries that had a global application by the beginning of the twentieth century. Gao Xi provides a case study of this development in her chapter on Patrick Manson and the medical missionaries in China beginning in the 1870s, but there are myriad examples of this from China and elsewhere. At the end of the century, Alexandre Yersin and Shibasaburo Kitasato made their dramatic discoveries of the cause of bubonic plague while working in Hong Kong; and before the outbreak of World War I, the Manchurian Plague Prevention Service hosted research by a team of international scholars. Other early global biomedical research included Ronald Ross's work on malaria in India, which won international notoriety (Nobel Prize in Physiology or Medicine 1902), as did the research of Alphonse Laveran in Algeria (Nobel Prize 1907). Algeria was also where Charles Nicolle made his discovery of the cause of typhus in 1912 (Nobel Prize 1928). In Brazil Oswaldo Cruz established an institute at the beginning of the twentieth century modeled on the Pasteur Institute, where he had trained.

This afterword looks at the history of Western medicine in China from the perspective of today's global health concerns. Comparing contemporary efforts to improve health for all can help in understanding the growth of Western medicine in China, which typically has been studied as an arm of imperial domination or the inevitable growth of Western science. Likewise, this history of Western medicine in China can help to understand global health today if it is studied as a precursor or early example whose similarities and differences help clarify what is new and what is a continuation of earlier efforts.

Any examination of global health and the history of medicine in China begins with the question of what is meant by global health. The problem is that the concept is not very well defined, nor is there much common agreement.