Ka-che Yip. Disease, Colonialism, and the State: Malaria in Modern East Asian History. Hong Kong University Press, 2009.
In a letter written in January 1854, Alvine, wife of William Lobscheid of the Chinese Evangelization Society, complained of suffering from Hong Kong fever. Not long after, she died during the hot summer month of August. In fact, Hong Kong fever was such a prevalent and deadly disease at that time that Dr. William Morrison, Colonial Surgeon, proclaimed in 1847:
There can be no doubt that the first colonization of the Island was attended with disastrous consequences to our countrymen and soldiers, and the ravages of Hong Kong Fever were as fearful as similar visitations have been in other parts of the world.
In the 1890s, it was determined that “Hong Kong fever” was, in most cases, malaria. The hot and rainy summer months provide ample opportunities for the anopheles mosquitoes to breed in foothill streams, valleys, and bodies of standing water. Despite the severity of the disease, the colonial government did not have a specific anti-malaria policy for most of the nineteenth century. Anti-malaria strategies were reactive and piecemeal and were essentially part of the colonial public health policy that was based on concepts of sanitation within an environmental framework. After World War II, anti-malaria efforts were carried out in tandem with the government’s broad public health care policies which focused on the elimination or control of epidemic diseases. Some scholars have argued that medicine and public health had been used consciously by imperial powers for political expansion, economic gains, or social control. Others have maintained that in many ways, the behavior of the colonial government could be understood as but “natural manifestations of political rule, be they colonial or otherwise.” Both interpretations, however, tend to understate the complexity of colonial rule and the importance of local factors in the development of colonial policies. Through an examination of the ways in which the colonial government in Hong Kong responded to the threat of malaria and the factors that shaped such responses, this chapter will provide a better understanding of the colonial administration’s policies towards diseases in general, the nature and significance of malaria control specifically, and the complexity of bio-political governance and colonial rule in Hong Kong.
Malaria in Hong Kong
Before 1890, malaria was not listed separately in the Colonial Surgeon’s annual reports but was included in the general category of “fevers,” although both recorded remittent and intermittent fevers were in most cases malaria. In 1890, the term “malarial fever” appeared in the summary of deaths and their causes, and the Colonial Surgeon’s report for 1891 contained a summary of the history and etiology of malaria in the colony. Exact statistics for the incidence of malaria from 1842 to the beginning of the 1890s were therefore rather sketchy and difficult to interpret, but the disease, which was most rampant in the eastern and western parts of the initial settlement, was certainly much feared by residents, especially the non-immune newcomers. One source claimed that the outbreak in the summer of 1843 killed 24% of the troops and 10% of the European civilians. The military was hard hit, and graves of many victims can be found in the military cemetery at Stanley. At that time, troops were moved around based on the accepted theory that “good southerly breezes” would disperse the “mephitic vapours which emanated from the damp soil, and caused the disease.” Malaria remained the main cause of death among British troops in the last years of the nineteenth century: in 1898, the malaria mortality rate was over 7 per 1,000 people. By comparison, the rate for the Chinese was 2.1 per 1,000 for the same year.
By the late 1890s, the parasites that caused malaria had been discovered and the role of mosquitoes in the transmission of the disease was understood. The first official scientific investigation of malaria was undertaken in 1899 when London instructed Hong Kong officials to collect mosquito specimens to be shipped to England for study. The following year, the Hong Kong government issued a report on the prevalence of mosquitoes, especially anopheles, in the colony and the means to deal with the problem. While some anti-malaria measures were subsequently introduced in the colony, it was not until 1930 that a Malaria Bureau within the Medical Department was established to carry out extensive systematic investigations.
The morbidity and mortality rates of many communicable diseases in the colony were to a significant extent affected by the constant movements of people between China and Hong Kong. From the 1910s to the early 1930s, the number of deaths from malaria ranged from 400 to 500 per year with a surge into the 700s in the early 1920s. To put this in context, the death rate per thousand from malaria was about 0.4-0.5 in 1929-30. This was slightly below the death rates for beriberi and about a quarter of those for pulmonary tuberculosis which had a mortality rate of about 2 per 1,000 people at the time. The rate remained basically unchanged until the immediate postwar period when an influx of returnees and Chinese refugees caused an increase in the incidence of the disease. The decades in the postwar period witnessed a marked decline in the number of deaths from malaria, thanks to controlled urban development and improvements in anti-malaria measures, public health education, and careful surveillance. Unfortunately, certain areas in the New Territories proved to be major loci of transmission; moreover, outbreaks in border areas in China where malaria is endemic, occasional influx of refugees from the mainland and Southeast Asian countries, and increased international travel resulted in the rise of imported cases. Although there were still sporadic indigenous cases, the total interruption of local transmission had been achieved by the end of the 1960s.
The Making of a Health/Malaria Policy: Environmental Issues
Before the late 1890s, the Hong Kong government did not have a specific anti-malaria policy. Trying to protect the health of the troops and residents (especially Europeans), the government gradually developed, in piecemeal fashion, policies that focused almost entirely on the improvement of sanitation which was considered to be the key in dealing with the many diseases, including malaria, cholera, typhoid fever, and dysentery, that were prevalent in the colony. Malaria was generally viewed as an environmental problem before the role of mosquitoes in its transmission was established. Marshes and swamps, especially with decomposing vegetation, were considered to be the chief cause of malarial miasma. The topography of the colony, consisting of stretches of flat land in the inland valleys with marshes and swamps, were deemed particularly favorable to the development of the disease. As Hong Kong grew and construction boomed during the first decades of the colony, many also argued that earth excavation disturbed the soil and created conditions conducive to the development and spread of Hong Kong fever. There were also debates about the wisdom of removing excessive vegetation near human residences in order to help reduce the problem of fevers. The colonial government in Hong Kong at first followed a strategy of removal with mixed results. By the beginning of the 1880s, the government reversed its policy, and an investigation into the causes of Hong Kong fever in the Western District in 1888 explicitly identified the absence of trees and plants as one of the problems. But, by the turn of the century, clearing excess undergrowth in residential areas was again considered a useful strategy for reducing breeding grounds for mosquitoes.
Such assumptions were central to European attitudes towards the environment in their imperialist expansion into alien lands in the nineteenth century: the colonies, especially those in the tropics, were hostile environments, but Europeans with their racial, moral and scientific superiority, could control the environment that contributed to the physical afflictions and even moral degeneracy among some of the new settlers. At first, Europeans found it necessary to seek “healthier” locations where they could control the environment and make it similar to that of their respective homelands. Hill stations in the upland areas of India or Southeast Asia were in essence “cordoned” places bounded by geographic, social, cultural and political distinctiveness. Just as in India and other tropical colonies, Europeans in Hong Kong sought havens away from the coastal lowland where they would be safe from malaria. At first, Happy Valley was considered as the site for the development of a new town in 1844, but it was found to be unhealthy and was consequently abandoned. A far better choice was the Peak where Governor Richard MacDonnell, who had experience living at high attitude in Africa, built a sanatorium. Other European officials and merchants quickly followed his example.
The Making of a Health/Malaria Policy: Chinese and Europeans
By the 1850s, there was a gradual broadening of assumptions about the causes of malaria: instead of identifying the malevolent environment as the sole source of the Europeans’ health problems, Europeans began to include the ways of life of the indigenous populations as part of the environment inimical to the survival of European colonists. The generally unsanitary conditions of the tropical colonies and alleged reservoirs of pathology among the indigenous populations were now also held responsible for the debilitating diseases that they suffered. Europeans now considered their civilizing influence essential to the improvement of conditions of the local populations. Not surprisingly, Europeans in Hong Kong increasingly identified the issue of sanitation with the lifestyle and living conditions of the Chinese community, and the anti-malaria policy that evolved became an integral part of environmental improvement and sanitation reforms—or public health rationality—of the colonial government.
Despite the colony’s reputation as an unhealthy place, Hong Kong over the years emerged as one of Britain’s most important trading posts in Asia, and continued to grow and prosper. The population increased by 82.5 % between 1848 and 1853: the number of Europeans rose from 642 to 776, that of the Chinese from 20,228 to more than 38,000. By 1911, the census revealed that the Chinese civil population had exceeded 440,000 while the non-Chinese civil population was 12,075. With the increase in population, the question of overcrowding in Victoria emerged as a major concern, but there was no significant investment in the public works infrastructure essential to the improvement of the health of the colony. London seemed determined not to allow Hong Kong to become a financial burden on Britain. In fact, the initial colonial civil establishment did not include a Colonial Surgeon as Henry Pottinger, Administrator of Hong Kong from August 1841 to June 1843, had recommended; and from the beginning, the government in Hong Kong had to deal with constant demands from London to economize in personnel and administration. Even after the Colonial Surgeon was appointed, his contacts were confined almost entirely to Europeans and other nationals. He was in charge of the government civil hospital, founded in 1850 after initial objection from London, and the facility catered mainly to the needs of members of the police force, civil servants, convicts, the destitute, or those able to pay for their service. Over the first few decades of the colony, the Colonial Surgeons were quite aware of the unsanitary conditions of the colony, but their pleas and recommendations for improvements in their annual reports were generally not heeded by the administration. Except for a contribution to the building of the Tung Wah Hospital in 1870, the government did not pay much attention to the Chinese community as far as health matters were concerned.
The overwhelming majority of the Chinese population, on the other hand, relied on traditional Chinese medicine for medical relief and they were suspicious of Western medicine, with its invasive practices of surgery. Public health measures such as modern methods of sanitation, segregation, or cremation were deemed intrusive, disruptive, or contrary to traditional beliefs, and the colonial government was reluctant to introduce measures that might prove to be offensive and provoke conflict. Certainly, the colonial government could, and would be coercive in imposing measures considered vital to the economic and social well-being of the colony. Yet before the outbreak of the plague epidemic in 1894, the colonial government did not find it necessary to integrate the Chinese community into the colonial health administration. Practitioners of traditional medicine were not required to register with the government, and the Tung Wah Hospital, which attended to the medical needs of the Chinese, used only indigenous medicine. The colonial government could argue that they were allowing the Chinese to follow their “customs and usages,” and that there was little that they needed to do for the Chinese community as far as medical matters were concerned.
Indeed, during the early decades of the colony’s history, the colonial government was disinclined to intervene actively in affairs of the Chinese population as long as there were no major challenges to law and order or serious health crises that threatened the conduct of trade and the colony’s prosperity. While the Chinese would be allowed to follow their own customs within the larger framework of British law, the government did introduce measures to control the Chinese population, including laws that specifically targeted the Chinese. It was also ready to collaborate with or manipulate Chinese elites and interest groups when necessary. Hong Kong at that time was essentially a segregated society. Europeans and Chinese lived in separate communities, with the latter mostly in the Tai Ping Shan area, having been forced to relocate there from the Upper Bazaar area in 1844 by the government. As noted, current assumptions about the cause of malaria as well as racial and cultural biases played a role in residential segregation: Europeans linked the prevalence of diseases to the “filthy habits of life amongst the…Chinese.” It is no accident that “cleanliness” was paired with “civilization” and it was generally believed that Hong Kong fever resulted from “the influence of an atmosphere which had never been subjected to the purifying influence of civilization.” The rhetoric of civilization constituted a central theme in colonial mentality in the nineteenth century, and Hong Kong fever became, in the eyes of the Europeans, closely identified with the unsanitary conditions as well as lifestyle and cultural practices of the Chinese who were unappreciative of the benefits of modern sanitary measures.
Such sentiments were expressed clearly in Governor G. William Des Voeux’s report to the Legislative Council in 1889, five years before the outbreak of the plague epidemic. The Chinese, insisted Des Voeux, lacked “some of the qualities which are essential to true progress.” He pointed to the Chinese lifestyle and living conditions as one of the obstacles. “The close packing of the Chinese in their houses which is the normal condition of all classes among them,” according to Des Voeux, simply could not be accepted or tolerated by Europeans, who, “unlike the Chinese who have…become inured and insensible to the conditions inseparable from extreme density of population,” were “rendered ill and miserable by the effects of habits which such insensibility produces.” It was in fact a widely held belief among Europeans that the Chinese were apparently immune to certain diseases prevalent in the colony.
Residential segregation in Hong Kong was therefore the rule. The rationale was to keep the filth and unhygienic conditions as far away as possible from the European community. As noted, most Chinese lived in the congested Tai Ping Shan area, where, in 1854, according to Colonial Surgeon J. Carroll Dempster, one could find “‘cowsheds, pigsties, stagnant pools’, the receptacles of every kind of filth.” The design of early tenement houses actually encouraged overcrowding and poor sanitation. Houses were deep and the street frontage narrow, with the ground floor partitioned into tiny cubicles, and a “cookhouse” at the rear served “as kitchen, latrine, urinal, and general backyard.” The second floor essentially repeated the layout. Windows were usually absent and the interior was poorly lit and ventilated, while sanitary facilities were totally inadequate. Sometimes each house had a drain from the cookhouse to the public sewer, but in most cases, the drain ran “from cookhouse to cookhouse under the party walls of adjacent tenement,” till it was brought out to the street. For most Chinese immigrants, poverty and family ties contributed to the congregation of a large number of people under one roof, living in squalor and extremely unhygienic conditions.
The original Chinese communities were to the east and west of the Europeans in the central district. But by the mid 1870s, some Chinese began purchasing European properties with the support of Governor John Pope Hennessy. Europeans demanded that exclusive residential areas be set aside since the Chinese could not be trusted to take the proper sanitary precautions against diseases. The solution was the introduction of residential reservations where Europeans had exclusive rights and would be “safe” from malaria and other diseases. Caine Road was one of the reservations set up in 1888. The “European District Reservation Ordinance” dictated that only “houses built according to European models, and occupied in much more limited numbers than is usual with Chinese,” would be allowed. By the turn of the century, as anti-malaria measures helped to remove the threat of malaria in the western part of the city, the government expressed confidence that “many sites hitherto avoided would probably ere long be made use for the erection of Europeans homes.”
Urban Improvements
Another strategy, which required time to carry out and involved substantial outlay, was to improve the health of the city through controlled urban improvement. The major concern was the city’s sanitary infrastructure and the design and construction of buildings. Although eventually various measures were introduced, lack of funds or vigorous opposition from property owners meant that quite often, ordinances were revised and watered down or not enforced at all. The result was a rather haphazard patchwork of legislation that failed to provide a comprehensive framework for public health reform. A major step was taken in 1859 when an Inspector of Nuisances was appointed by Governor John Bowring to deal with general problems of sanitation in the colony, including drains, water supply, and scavenging. Sanitation problems persisted, however, and in 1862, an outbreak of cholera led to the creation of a Sanitary Committee which promptly recommended the proper development of the drainage system. But London was not prepared to let Hong Kong make such improvements without clear proof that local funds were available. Some improvements were made in the Tai Ping Shan area in 1866, but certainly not enough for Dr. Phineas Ayres who became Colonial Surgeon in 1873. Dr. Ayers was so thoroughly disgusted with the poor conditions that he criticized in his 1874 report the problems of congested and unhygienic buildings, drainage, and the lack of infrastructure. But he received no support for his proposed reforms. The military, however, demanded action because the unhealthy state of affairs was threatening the well-being of the troops.
Mr. Osbert Chadwick, a sanitary engineer, was dispatched to Hong Kong in 1881, and his report, presented the following year, represented a most comprehensive evaluation of the health of the colony at that time. Noting the extremely defective sanitary infrastructure and building codes, he recommended improvements in drainage and sewage, water supply, scavenging, the construction of public facilities, as well as new building ordinances mandating the provision of open spaces to reduce overcrowding. Unfortunately, except for the creation of a Sanitary Board in 1883 and the passage of a Public Health Bill four years later which introduced some changes in building designs, Chadwick’s recommendations were in the main not followed through. Dr. Ayres became so disheartened by the deteriorating conditions that he stated in his 1883 annual report:
those that think sanitary work in Hongkong is being overdone are evidently ignorant of the want of it, and unaware of the mine that has been forming of late years, that some day may be sprung with most disastrous results.
Plague and Malaria
The outbreak of bubonic plague in early 1894 in the Tai Ping Shan district proved that Ayres was right. Hong Kong was declared an infected port on May 10 and the death toll rose from 450 at the end of May to 2,442 in July. The fact that plague had broken out in the overcrowded and unhygienic Chinese tenements seemed to validate the cultural assumptions of Europeans that the filthy living conditions and habits of the Chinese were responsible for the presence of Hong Kong’s health problems, including malaria, and that the Chinese were unwilling or incapable of following the rules of behavior of a modern civilized society.
Economic imperatives and international isolation dictated immediate action. The plague epidemic directly threatened Hong Kong’s position as a premier shipping and commercial center and British interests in Asia—the very survival of the colony was at stake. As an infected port, Hong Kong suffered greatly from lost revenue as shipping declined and prices began to rise. Governor William Robinson proclaimed that: “without exaggeration, I may assert that so far as trade and commerce are concerned the plague has assumed the importance of an unexampled calamity.” Its impact on trade and Hong Kong’s future could be crippling. Unlike malaria, the plague epidemic was dramatic, terrifying, highly visible, and a direct threat to public order. It subjected Hong Kong to international sanction and served a severe blow to the colony’s international reputation.
Compared to its rather reactive policy towards malaria, the colonial government’s response to the plague outbreak was swift and decisive. It cordoned off the Tai Ping Shan area, relocated residents, imposed house-to-house inspections and compulsory removal of the sick, and fumigated and condemned houses. To many Chinese, such measures as the government deemed vital to the elimination of a crisis threatening Hong Kong’s economic viability proved to be highly intrusive and insensitive to Chinese cultural traditions. The government rejected protests from the Chinese community as well as requests from representatives of the Tung Wah Hospital to assume responsibility for treating Chinese patients. In fact, when practitioners of Chinese medicine and the Tung Wah Hospital proved unable to deal with the disease, some government medical officers called for the abolition of the hospital. The compromise reached between the government and Chinese leaders led to the curtailment of power of the Tung Wah leaders, supervision of the hospital by the Medical Department, and the introduction of Western medical treatments in the hospital.
The more or less chronic problem of malaria did not provide the government with the needed jolt to carry out greatly overdue sanitary improvements, especially when they aroused opposition from powerful property owners and other vested interests, as well as only limited interest in London. The administration had been reluctant to intervene directly in the Chinese community; but the plague outbreak changed that. The colonial government already had the power, if it wished to exercise it, to impose any sanctions—political, social, and cultural—deemed necessary to arrest the spread of the epidemic so as to ensure the economic well-being and public order of the colony, as well as protect the colonial elite and the local population. The plague provided the opportunity for direct government intervention, and a rationale to introduce an array of measures—some of them highly intrusive, to deal with the epidemic. New ordinances targeted sanitation problems in buildings and the Sanitary Board was given expanded power, although it would be seven more years before the Board was reconstituted to include a Principle Civil Medical Officer as President. The number of deaths caused by plague declined towards the end of the year, and 1895 was free from plague. But it came back in full force in 1896, and in 1899 it killed 1,434 people; it became an almost annual occurrence until 1929.
Anti-malaria Work
The anti-plague measures also provided the impetus to develop strategies to deal with malaria. At the same time, the work of Patrick Manson, Ronald Ross, Giovanni Battista Grassi and others had, by 1898, finally solved the mystery of malaria transmission. There was, in fact, a Hong Kong connection in the search for the malaria vector. After serving as a medical officer for the Imperial Maritime Customs in Xiamen (Amoy), Patrick Manson started his medical practice in Hong Kong in 1884. He had been studying the stigmatizing disease of elephantiasis and how it was acquired, and tried to establish a link between the filarial worm and mosquitoes. Although he failed to chart the cycle of the filarial worm in the mosquito and the human body, his work pointed to the important role of biting insects in the transmission of diseases. In Hong Kong, Manson became interested in malaria and tried in vain to understand the part played by mosquitoes in carrying malaria. Unable to perform the necessary experiments himself, Mansion persuaded Ronald Ross, a member of the Indian Medical Service, to do so and in 1897 he discovered developing stages of malaria parasites on the stomach wall of mosquitoes fed on patients with malaria parasites in their blood. The work of others would identify that only certain mosquitoes acquire malaria, a point that Ross was unable to establish. In Italy, Grassi and his team of researchers also declared that they had actually beaten Ross to similar discoveries. These scientific discoveries offered a new vector-centered approach in the anti-malaria effort.
As noted, in 1899, London instructed the Hong Kong government to collect mosquito specimens for study. Even though the reasons that had deterred the government from taking action in the past—an unwillingness to pay for costly sanitation and drainage improvements on the part of London, the Hong Kong government and the rate payers—still existed, there was now a sense of urgency after the devastating impact of the plague epidemic. Moreover, the vector-centered approach seemed to be less costly than large-scale public health improvements. An Insanitary Properties Ordinance was passed in 1899 which provided for open space in the rear of every building and limited the number of cubicles and partitions. A broad anti-malaria program was introduced in the same year and, with later modifications, continued throughout the prewar period. The thrust of the program was to control the breeding of mosquitoes and the destruction of the vector. Sanitary inspectors searched for larval breeding places, and standing water was treated with kerosene or carbolated creosote. In certain areas, nullahs were redirected to allow for proper drainage and ravines were converted into well-paved nullahs. By 1900, this had been carried out in the central district and work began in the western part of the city. The two anti-vector measures—nullah drainage and elimination of larval breeding grounds—were supported by two specialists, Professor J. Simpson of the London School of Tropical Medicine, and Osbert Chadwick, who visited Hong Kong in 1902 to assist in the anti-malaria and anti-plague efforts. Simpson, however, cautioned that as long as there was free movement of people between China and Hong Kong, it would be difficult to prevent imported cases and carry out quarantine or surveillance.
The government also initiated public health education programs, distributing pamphlets in both Chinese and English on malaria and mosquito control and destruction. In schools, lessons on hygiene which included discussions of infection by mosquitoes were taught and students were urged to take action in eliminating mosquitoes. Weekly reports of all malaria cases from hospitals were sent to the Medical Officer of Health for study. Moreover, the government administered quinine to school children in selected districts. An interesting indication of the changes in the role of the Tung Wah Hospital is that the hospital staff routinely gave injections of quinine to patients and spread health propaganda. Total deaths from malaria remained at an average of 431 per annum from 1900 to 1904, 447 from 1905 to 1909, and 378 from 1910 to 1914, but there was a reduction of almost 60% in malaria deaths from 1910 to 1914. By 1928, malaria accounted for less than 2% of deaths each year.
Scientific studies of malaria and mosquito species were also undertaken by the Bacteriological Institute which carried out microscopic examinations of malarial parasites. In 1913, results of investigations were sent to the Imperial Bureau of Entomology in London at the latter’s request, in anticipation of the official opening of the Panama Canal the following year. The Canal Zone had been plagued by problems of yellow fever during construction of the canal, and the British government became particularly concerned with the increased risk of Hong Kong being affected by imported cases of mosquito-transmitted diseases, which would in turn jeopardize the economic well-being of the colony. There were grounds for concern: plague continued to be a problem in Hong Kong, and the report of Osbert Chadwick in 1902 had revealed the lack of improvements to sanitation that had been made since his last visit. Chadwick in fact lamented that the housing conditions were “rather worse than better than it was in 1882.”
Public Health and Building Improvements
The persistence of unsanitary conditions and the discovery of the role of mosquitoes in malaria infection seemed to validate in the minds of Europeans their assumptions that the unhygienic living conditions and way of life of the Chinese contributed not only to the outbreak of plague, but also to the development and spread of other diseases, including malaria. It was claimed that as a result of unsanitary conditions, the Chinese quarters created a favorable environment for mosquito breeding, and that the Chinese had failed to take precautions to prevent infection. There was renewed clamor for the physical segregation of Chinese and European communities; in 1902, partly on the grounds of malaria control, a sub-committee of the Sanitary Board recommended that an area of about 20,000 acres between Tsim Sha Tsui and Kowloon City be reserved for that purpose. The principle of segregation was supported by Joseph Chamberlain, Secretary of State for the Colonies, who proclaimed that in the reservation, “people of clean habits will be safe from malaria.” But he “objected to excluding Chinese of good standing so as to give Europeans low rents.” He decreed that the Governor would have the authority to make exceptions for approved Chinese residents. The same principle was applied to another reserved area in the Hill District two years later.
The investigation of Simpson and Chadwick provided the impetus for the passage of the Public Health and Buildings Ordinance in 1903 which, in addition to introducing new measures, consolidated various pieces of legislation passed since 1887, and remained in force until 1935. Of particular importance to public health and town planning were new stipulations about open spaces and scavenging lanes as well as specifications for private streets, building heights and the types of buildings to be erected. Moreover, kitchens of tenement dwellings were allowed to extend across only one half of the width of the house, thereby enabling the long narrow rooms to be adequately lit and ventilated.
The Public Health and Buildings Ordinance also provided for the inspection of premises for the presence of mosquito larvae. If any such evidence was found, owners or occupiers of the premises were charged with the removal of any accumulation of water or other potential breeding grounds and the taking of preventive measures against the breeding of mosquitoes. Yet this law did not apply to the New Territories. In fact, the continual urbanization, environmental improvements, and more efficient drainage of the island meant that by the beginning of the 1930s, the densely populated areas of both Victoria or Kowloon were relatively free from malaria while most of the new malaria cases were found in the suburbs and the New Territories. Much infection among the troops took place in the outlying rural districts where soldiers camped and trained. Environs of stations along the Kowloon-Canton Railway—especially in Tai Po and Fan Ling—were rife with malaria and health officers gave injections of quinine and prophylactic doses of the drug to the staff. There were, however, no large-scale systematic investigations of anti-malaria work in the New Territories until the establishment of the Malaria Bureau in 1930.
The Malaria Bureau
In 1928, Surgeon Commander David Given, Naval Health Officer, Singapore, criticized the lack of research into the malaria problem in Hong Kong and recommended the creation of a Malaria Bureau. Given’s study and the Hong Kong government’s recognition of the severity of the problem finally prompted it to take action. A year later, Dr. A.R. Wellington was appointed Director of Medical and Sanitary Services. He was entrusted with two major tasks: the reorganization of the medical and sanitation services, and the control of malaria. The vigorous enforcement of anti-rat measures and the mandatory cleansing and lime-washing of buildings had helped to eliminate plague as a health threat; malaria, however, remained a problem. The following year, a Malaria Bureau headed by a government malariologist, Dr. R. B. Jackson, was established in the Medical Department to co-ordinate the anti-malaria efforts and carry out scientific studies of mosquitoes and the disease. The Bureau’s work included a general mosquito survey of the colony, investigation of the prevalence of malaria and other mosquito-borne diseases, the catching of mosquitoes and their identification, co-operation with other government departments and hospitals in the anti-malaria effort, and the training of staff members. It co-operated with the Bacteriological Institute, which examined blood films for malaria parasites, and the Public Works Department to target problem drainage areas. The government allocated specific funds for drainage programs that included redirecting nullahs, sewerage, and drainage. The Bureau’s work helped to identify Anopheles minimus and A. jeyporiensis as the two main culprits in malaria transmission in Hong Kong.
The government also turned its attention to the malaria problem in the New Territories. Since the acquisition of the New Territories in 1898, the government had gradually extended health programs into the area, e.g., a sanitation squad had been put in place in certain villages, dispensaries were established, and government midwives were stationed at certain locations. The Malaria Bureau worked with all these units in its investigation of malaria, including taking mosquito surveys and spleen census, and examining blood samples to search for the presence of parasites. The bureau found local residents to be co-operative and reported that “there is no opposition to scientific investigation, provided the people understand the objects aimed at and are treated with ordinary tact and civility.”
As noted earlier, the death rate of malaria remained at the 400-500 range in the early 1930s. Towards the latter part of the decade, however, both the morbidity and mortality rate of malaria increased as a result of the influx of Chinese refugees. The outbreak of the Sino-Japanese War in 1937 and the Japanese occupation of areas across from Hong Kong led to steady streams of refugees seeking a safe haven in the colony. The government of Hong Kong set up three semi-permanent camps and five rural camps to shelter the newcomers, and their care was entrusted to the Medical Department. Many refugees, malnourished and already suffering from lack of health care, were particularly vulnerable to the outbreak of epidemics in overcrowded conditions. A smallpox epidemic broke out in 1938 despite a vaccination campaign, and cholera cases mounted in the summer of 1939. The number of deaths in the colony from malaria also increased from 733 in 1938 to 1,492 in 1939. The infection rate of 25% in one of the camps testified to the severity of the problem. The government continued its anti-malaria work as much as was possible, including oiling and drainage work carried out by the Public Works Department.
By the beginning of the war, Hong Kong was a prosperous city with a population of more than 1.5 million. It had undergone rapid economic expansion, and public revenue rose from $17,728,000 in 1921 to $41,478,000 in 1939. Over the same period, expenditure for sanitation services had more than doubled, from $536,438 to $1,148.034. Although tuberculosis, smallpox, cholera, and to a lesser extent, malaria, remained major health problems, plague had virtually disappeared, and the government had developed strategies for the control of malaria.
Postwar Reconstruction
The end of the war marked the beginning of government efforts to repair damages to the health infrastructure caused by the Japanese occupation. Anti-malaria work had lapsed during that time, and the incidence of malaria “had reached almost epidemic proportions,” according to the medical officer in charge in the Royal Navy Mobile Malarial Hygiene Unit. Moreover, Japanese construction during the occupation had contributed to more problems. For instance, at the Kai Tak airfield, the large artificial gully encircling the perimeter constructed by the Japanese had become an ideal breeding ground for mosquitoes. In view of the severity of the situation, the government decided to have the Royal Navy carry out aerial spraying of dichloro-diphenyl-trichloroethane (DDT) in January and February 1946 to reduce the breeding of mosquitoes and flies. The entire city of Victoria, the Kowloon Peninsula, and some suburban areas were covered in the operation. Apparently, this was the only large-scale attempt to apply DDT to the pest problem, but the result proved to be discouraging. Although some of the flies infesting open spaces and mosquitoes breeding in exposed water were destroyed, the insecticidal spraying was found to be unsafe and ineffective for urban areas. No more aerial spraying was recommended.
The exit of the Japanese also witnessed the return of the population that had been forced out by the Japanese during occupation as well as a rising tide of new immigrants who wanted to escape from the civil conflict in China. The population increased from an estimated 600,000 in September 1945 to more than 2.2 million in 1953. In the immediate postwar years, the government was reluctant to develop any long-term plans for the housing of refugees based on the assumption that many of them would only stay temporarily, and that any substantial increase in social and medical care for them would in fact attract more immigrants. The government’s expenditure on refugee health care was therefore kept to a minimum. The administration relied on the social relief services of charitable and philanthropic organizations, including international and religious agencies, to meet the increasing demand for aid. By 1949, with the founding of the People’s Republic of China, it became clear that the newly arrived immigrants were going to stay.
The Hong Kong government reacted to these developments cautiously but there was little enthusiasm for the idea of a welfare state. However, the squatter fire at Shek Kip Mei on Christmas Day 1953, that rendered 50,000 squatters homeless, led to the establishment of the Resettlement Department and the provision of public housing through the construction of Resettlement Blocks for disaster victims. Clearly, the government’s social and health policies had to take into account the new postwar realities and broader issues of social policy needed to be addressed, even though the basic concern for the colony’s economic development and stability remained unchanged.
The government sought the co-operation of voluntary organizations in areas of social welfare and health care. In fact, activities of religious organizations filled the gap of health care that the government failed to provide for the poorer segment of the population during the 1950s and 1960s. Charity clinics, run by missionary societies and other voluntary associations like the Kaifongs, offered low-cost medical relief to thousands of patients turned away from congested government outpatient clinics. These clinics, staffed almost entirely by unregistered doctors who had no place in the official health care system, made it possible for the colony to continue to limit its investment in health care and social services.
Malaria Control Strategies
The colonial government did invest in health services that were perceived to have a direct impact on the colony’s economic well-being and expansion. The control of epidemics and communicable diseases as well as the development of epidemiological services received priority funding from the government. In addition to tuberculosis and malaria, the government also paid special attention to major international diseases subject to quarantine such as cholera, smallpox, plague, and typhus. According to the annual report for 1955-56 written by the Director of Medical and Health Services, the major services provided by the Health Division included: hygiene and sanitation, vaccination and other forms of immunization, port health, anti-tuberculosis services, anti-malaria services, social hygiene, maternal and child health, school health, health education, and industrial health. The Division also shared with the Urban Services Department of the Urban Council the responsibility for improvements in general environmental conditions in the city area. While the government was not prepared to provide medical services for the entire population, it did assign priority funding and support to the development of a healthy environment that was deemed essential to economic development and expansion.
Throughout the 1950s and 1960s, the Medical and Health Department continued to improve the general sanitation conditions of the colony. After the war, it tried to re-establish sanitation controls and rebuild and expand upon the prewar preventive infrastructure. Prophylactic vaccinations against smallpox, cholera, enteric fever and diphtheria were available free of charge, and government clinics provided free treatment for most communicable diseases. An extensive vaccination campaign led to the eradication of smallpox in June 1952, and cases of tuberculosis also declined as a result of wide-scale bacillus calmette-guerin (BCG) vaccination supported by the World Health Organization (WHO). The Malaria Bureau was re-established, and malaria became a notifiable disease in September 1945 (although notification was abandoned for unknown reasons between May 1948 and June 1950). The number of cases remained high: 2,422 in 1946, 1,305 in 1952, and 858 in 1954. It is evident however that the number of deaths from malaria was declining in the same period: 720 in 1946, 46 in 1952, and 16 in 1954. By the 1960s, mortality had fallen to single digits, and no deaths had been recorded in some years.
Hong Kong did not participate in the global malaria eradication campaign initiated by WHO in 1958. DDT had revolutionized the vector-based strategy of malaria control and there was optimism among many countries that this technological solution would be the panacea for malaria eradication worldwide. After the insecticidal aerial spraying in 1946, health officials in Hong Kong had concluded that the use of blanket residual spraying of DDT that characterized the campaign in many other parts of the world was not only inappropriate but also unnecessary. The report prepared by government malariologist Dr. K. H. Cheung, after attending the WHO Third Asian Malaria Conference in Delhi in March 1959, stated that the anti-larval measures adopted by the government had been effective and economical. Moreover, any large-scale spraying had to cover large areas of frontier land and regions over which the Hong Kong government had no control. In fact, by the second half of the 1950s, the geographical distribution of the disease indicated that built-up urban areas were essentially free of malaria, while malaria transmission was confined largely to certain areas in the New Territories, especially Sai Kung. The government’s strategy was to continue and enforce anti-larval measures in the “protected areas”, i.e., the entire urban region comprising Hong Kong Island and most of Kowloon. The anti-vector measures of proper drainage, selective sanitary improvements, and the oiling and destruction of actual and potential larval breeding places had proved to be successful and cost effective, although there was no overall vector control program in the rural areas. Limited residual spraying was reserved for specific locations outside the “protected areas” and in the New Territories. Moreover, all infants attending clinics underwent blood examinations for parasites, and in 1958, the government began a pilot program of giving prophylactic plaudrine, a synthetic anti-malarial drug, to residents in Sai Kung.
Health education became an integral part of anti-malaria efforts. Health talks in schools and community centers focusing on the principles of environmental hygiene and prevention of diseases, distribution of leaflets, house-to-house visits to maintain contact with cases, and propaganda through the mass media all helped to promote awareness of the disease and control methods. The government actively sought the cooperation of voluntary organizations such as the Kafongs in health propaganda.
Hong Kong’s decision not to participate in WHO’s global DDT malaria eradication program proved to be a sound one. In 1969, WHO, recognizing the error of adopting the unitary approach of relying on DDT while ignoring local conditions, declared an end to the global anti-malaria campaign. In that same year, the interruption of local malaria transmission in Hong Kong had been achieved through incremental changes and methods that had been tailored to local conditions.
Achieving Control
While there were no indigenous cases reported from 1969 to 1976, a brief resurgence did take place in the early 1980’s in the New Territories, mainly as a result of the movement of large numbers of people with low immunity against the disease into developing new towns in areas that were vector-infested in the past. The government continued its strategy of early case detection and notification, vector control and health education, and the number of indigenous cases were reduced to 3 in 1985 from a high of 30 in 1983.
But the major concern was the imported cases. Since the early 1970s, although imported cases from China were still a problem, “army and police personnel and their families, and immigrants from Pakistan, India and Nepal made up the largest proportion of the imported cases.” Moreover, expanded tourism was accompanied by travelers from malaria-endemic regions. The Hong Kong Medical and Health Services maintained careful surveillance to identify the disease and eliminate loci of transmission. The late 1980s, however, witnessed the most serious crisis resulting from the influx of Vietnamese boat people. Infectious diseases such as measles and malaria spread in the detention camps, and there was a serious outbreak of cholera in early September 1989. Later that month, at least 115 Vietnamese boat people had contracted malaria; by the end of October, more than 500 cases of malaria had been reported in the Hei Ling Chau detention center. In 1989, 744 cases of malaria had been reported, as compared to only 98 the previous year. Of these cases, 741 were imported, with Vietnamese boat people accounting for 683.
In addition to active surveillance and early detection of cases, the government mandated that all malaria patients be treated in a hospital to ensure the treatment regimen was completed and that there were no possibilities for the disease to spread. A central reference laboratory for the identification of malaria was established in August 1984; it acted as a central monitoring unit to provide support to government and private pathology institutions and helped to ensure accuracy in malaria diagnosis. It also offered training in the preparation of blood slides and malaria parasite identification. Indeed, by the 1970s and 1980s, with medical and scientific advances, the anti-malaria effort increasingly combined the traditional vector control measures with chemotherapy. Since the majority of cases in Hong Kong were vivax malaria, which is usually mild, and drug resistance was not a problem, epidemiological control was more appropriate. Falciparum malaria, which is serious and requires timely clinical treatment, had to be dealt with by both epidemiological control and chemotherapy. At the same time, since the majority of falciparum cases in Hong Kong were imported, especially chloroquine-resistant P. falciparum which is a major threat in Southeast Asian countries, careful monitoring of imported cases from those countries remained a high priority.
There are important reasons for Hong Kong’s postwar success in its anti-malaria efforts. Recognizing the importance of providing a healthy environment for economic reconstruction and development, the colonial government in the early decades of the postwar era decided not to offer comprehensive medical care for the entire population; instead, it invested heavily in a public health policy that targeted the control and prevention of communicable diseases through environmental hygiene, improvements to sanitation, immunization campaigns, widespread health education, free health care for patients of most infectious diseases, and school health programs. As far as malaria was concerned, specific anti-malaria measures that included anti-vector activities, the limited use of DDT, the gradual expansion of “protected areas,” and chemotherapy proved effective. At the same time, there had been overall improvement in the health of the population; the mortality rate (based on all causes) in 1912 was 2,069 per 100,000 of population; it was 748 in 1948 and 501 in 1971.
In fact, an epidemiological transition, i.e., a change in health (morbidity and mortality) patterns, had occurred in the late 1960s. This was demonstrated by the decline in mortality from infectious, respiratory and intestinal diseases. As noted, smallpox had been eliminated, tuberculosis had been decreasing in significance as a cause of death, and local transmission of malaria had been disrupted. Even the poorer segment of the population had some access to modern Western and traditional Chinese medical care provided by the government and/or voluntary or charitable organizations. By 1970, Hong Kong’s major health problems were related to non-communicable diseases: the five leading causes of death were “cancer, heart and hypertensive diseases, pneumonia, cerebrovascular lesions and tuberculosis,” in that order. The changing pattern of mortality is reflective on the one hand of the efficiency of control measures of infectious diseases, and on the other, the heightened risks of the diseases of ageing resulting from increased life expectancy and modern urban developments and lifestyle. Hong Kong had begun to assume the characteristic health patterns of a developed country.
The transition was accompanied by urbanization, development of infrastructure, and general improvements in living standards and socio-economic conditions. Living standards had steadily risen, and incomes had increased substantially between 1976 and 1986. Real income “from main employment grew at an average annual rate of 7% between 1976 and 1981 and at a rate of 2.2% between 1981 and 1986.” The rate of school attendance for children at every age level from 6-18 had also improved greatly during this period. In short, within a span of about four decades after the war, Hong Kong had developed into an affluent society with a fairly well-educated population. All of these factors contributed to the emergence of a “modern” health profile.
Conclusion
In reviewing the development of an anti-malaria policy in Hong Kong, it is clear that the colonial government, interacting with local forces, played a crucial role in determining priorities and approaches in the attempt to control the disease. Throughout the prewar years, actions taken by the government of Hong Kong were, to a significant extent, shaped by current knowledge of the disease as well as cultural and racial assumptions. At the same time, they were conditioned by available resources, both in the colony and those forthcoming from London.
The prewar years witnessed the gradual evolution of an anti-malaria policy that was closely linked to reforms in sanitation and improvements to urban infrastructure, although changes had been slow and were carried out in a piecemeal fashion. The approach had been mostly reactive, and a comprehensive public health policy was absent. The plague epidemic of 1894, as well as scientific advances in the understanding of malaria transmission in the late 1890s provided the much needed impetus toward a clearer definition of the anti-malaria effort, now focused on anti-vector measures, sanitary improvements, and scientific investigations. Throughout this period, colonial policy and local factors interacted in shaping health policies in general and anti-malaria policies specifically. The primacy of economic concerns dictated London’s reaction to developments in the colony, but the unwillingness to allow the colony to become a financial burden also made London reluctant to provide funds for large-scale public works projects.
Initially, the decision to let the Chinese population follow their “customs and usages” so long as they did not threaten or jeopardize the colony’s political, social, and economic well-being contributed to some extent to the Hong Kong government’s somewhat hands-off policy toward the Chinese as far as health matters were concerned. The fluid immigrant population and society, especially in the early years of the colony, also discouraged the formulation of long-term policies. Further complicating the situation was the power of property owners who resisted the imposition of restrictions on the use of their properties that would, in the view of the government, improve the general health of the colony. It is important to point out, however, that the general rise of living standards among an “up-and-rising working class,” as well as a Chinese elite who was increasingly attuned to and familiar with changes of modern social and economic life, including the modern health and medical facilities now available, made the local population more willing to co-operate with the government in carrying out sanitation measures that helped to ensure some success in anti-malaria efforts. At the same time, by the latter part of the prewar period, the colonial government had gradually moved away from the position that the Chinese population in Hong Kong were not actors who could play an active role in health matters; it began to assume a more proactive attitude and the old view that the local Chinese community could largely be left to its own devices faded.
The rapid political, social, and economic changes in the postwar years led to a reevaluation of health policies on the part of the colonial government. The transformation of the colony from an entrepot to an industrial city was accomplished partly as a result of the political and social stability maintained by the government, in addition to the hard work, resourcefulness and business acumen of the Chinese population. While still wary of programs and projects that “might put an unbearable burden on the colonial treasury” which in turn “would put at risk Hong Kong’s financial independence from London,” the government invested heavily in the development of the educational system to create a pool of skilled labor, as well as in public health services that would provide a healthy environment in which the economy could grow.
Hong Kong has benefited from some successful anti-malaria measures taken by the mainland Chinese provinces across its borders. Yet, the colonial state had undoubtedly played a significant role in the disappearance of malaria as a major health threat. The anti-malaria effort became part of the broader public health policies in the postwar era. As noted, while the government was not willing to invest in comprehensive medical care for the entire population, it did attempt to provide adequate care for those who could not afford private medicine, either through government agencies or voluntary organizations. Moreover, it invested in infrastructure, public health, and general sanitation improvements. Economic imperatives remained paramount. The Medical White Paper 1964, for example, made it clear that:
a good general standard of health throughout a community is an economic asset to it and helps to condition the levels of energy and initiative which determine productivity, particularly in a free enterprise economy such as Hong Kong, and that “the economic loss due to sickness or disability, both to the individual and to the community, should not be underestimated.”
The increasing state intervention in social and health matters between 1945 and the mid-1980s had contributed to the economic success of the colony, while at the same time laid the foundation of a public health infrastructure that proved to be instrumental in protecting the health of the population. Yet, changes in the medical and health structures in the late 1980s and the early 1990s had to some extent undermined public health services. The establishment of the Hospital Authority in 1988 (formally set up in 1990) had certainly improved medical care, but this was accomplished at the expense of strengthening public health activities. Funds allocated to the Hospital Authority far exceeded those to the Department of Health which was responsible for the maintenance and expansion of public health services for the entire population. This budget shortfall persisted after the retrocession of Hong Kong to China. Just as Hong Kong was and is still vulnerable to imported cases of malaria from the mainland and other regions, it could also fall victim to newly emerging global diseases. Indeed, public health crises after 1997, especially the outbreaks of avian influenza in 1997 and Severe Acute Respiratory Syndrome (SARS) in 2003, clearly revealed weaknesses in the public health structure, especially in the disease surveillance and communication systems as well as in cross-border collaboration. A major legacy of the colonial system is the public health infrastructure, but there is still the need to strengthen and redefine that structure to meet current and future challenges.