Ka-che Yip. Disease, Colonialism, and the State: Malaria in Modern East Asian History. Hong Kong University Press, 2009.
In 1965, the Nationalist government in Taiwan declared that malaria had been eradicated and the World Health Organization (WHO) officially certified the accomplishment in November of that year. This was a major step for the Nationalists who had tried, first in the mainland after the founding of the new government in1928, and then in Taiwan after 1945, to deal with the many prevalent infectious and parasitic diseases that had been a major scourge of the Chinese population. To better understand the significance of malaria eradication in Taiwan, it is important to put the Nationalist government’s anti-malaria programs in the broad historical perspective of developments in the colonial and postcolonial periods.
This chapter is not a detailed chronicle of postwar Taiwan’s anti-malaria efforts although it will highlight the major steps taken. Rather, it focuses on several themes that provide the analytical framework for our understanding of the Nationalist success: the legacy of the Japanese colonial state; the role, philosophy, and strategy of the Nationalist state in health planning and disease control in the mainland and in Taiwan; the dominance of the biomedical and technological approach in public health; the development and consequences of a global anti-malaria campaign; and the emergence of a postwar hegemonic political and economic order that helped to shape the politics of international health.
The Legacy of the Japanese Colonial State
The health and anti-malaria programs introduced by the Japanese colonial government in Taiwan after 1895 constituted one of the legacies inherited by the Nationalist government after it reclaimed the island in 1945. The chapters by Liu Shiyung and Ku Ya Wen in this book have detailed the Japanese colonial state’s formulation and development of anti-malaria strategies during its rule; here, I shall only focus on the themes that are relevant to my study of the Nationalist efforts after 1949: the role of the state in fighting malaria, the hegemonic role played by Western biomedicine in this process, and how the Japanese colonial legacy affected the Nationalist approach.
Three years after Japan occupied Taiwan in 1895 Goto Shinpei, the Civil Affairs Bureau chief, reorganized the colonial administration into a highly coercive structure in order to facilitate political and social control, and the implementation and enforcement of public health measures to deal with the spread of infectious and parasitic diseases. It was a centralized structure that operated through the central government, the regional government in various prefectures, and the local government in towns and villages. Two administrative features were also introduced: the creation of a highly centralized and unified civil police, and the integration of this police force into local communities through the local self-policing hoko system. The close working relationship between the hoko headmen and the police injected into the basic level of Taiwan society the repressive and coercive power of the colonial state. The duties and authority of the police were wide-ranging: they included law enforcement; tax collection; censorship; control of movement of residents; supervision of bath-houses, hotels, restaurants, and slaughter houses; and administration of sanitation matters.
The police officers, with extensive power over local community affairs and collaborating with the hoko units, proved to be an effective instrument in the implementation of public health policies. At the central level, the health department, with sections in charge of medical affairs, hygiene, epidemic prevention etc was located within the Police Headquarters in the Civil Affairs Bureau. Prefectural police offices had their own health departments, and health police existed at the lowest administrative level to enforce health measures. With the support of the hoko, the police helped to introduce modern health reforms; mobilize the population to clean houses, streets, and sewers; maintain effective quarantines in times of epidemics; enforce mass vaccination; and conduct health education campaigns. Indeed, the police system served to introduce and uphold another vehicle of colonial hegemony under the Japanese: Western biomedicine and practices.
Japan, as a late comer to the business of colonial empire-building, quickly established the hegemony of biomedicine in its anti-malaria efforts to advance the cause of Japanese colonialism in Taiwan. Goto subscribed to the prevalent idea of “scientific colonialism” which rationalized colonial policy and social engineering while placing even more weight on biological principles in explaining the need to improve the infrastructure of Taiwan society, including public health. As he explained:
In this era of scientific progress, the basic principle of colonization has to be built on biology…It is to encourage a scientific way of living, from which are derived the system of industrial production, hygiene, education, transportation, and law enforcement. It is also to realize the principle of survival of the fittest in this competitive world.
Scientific medicine was modern and progressive, and through the improvement of the health of the local population—which would ensure a healthy labor force—as well as sanitary conditions in the island, it not only helped to advance the cause of Japanese economic interests, but also the self-legitimizing images of scientific humanitarianism. Goto criticized the Chinese government’s failure to promote medical studies in Taiwan as “disregarding people’s lives.” In fact, he compared the role of medicine with that of religion, noting that while Japan could not use established religions—as Western imperial powers had—to gain support from colonial peoples, medicine could serve the same purpose. Scientific medicine combined the benefits of the paternalistic benevolence of the colonial state, the civilizing mission, and the progressiveness of modern society. Quarantine regulations were promulgated, some public works were constructed to improve the sanitation and sewage systems, and people were vaccinated even when they objected. By the early 1910s, the colonial government proudly proclaimed that “it is encouraging to note that the natives are rapidly becoming alive to the efficacy of modern medicine and sanitary measures.”
The colonial government’s anti-malaria strategy of suppressing malaria relied mainly on the use of Robert Koch’s method of compulsory blood testing of residents and treatment with quinine of suspected and confirmed cases in pilot areas. As Ku Ya Wen points out in her chapter in this book, this “human approach” was less costly than large-scale environmental improvements and malaria eradication was not part of the initial strategy. Despite a brief change to an anti-mosquito approach in the early 1920s, the use of quinine prophylaxis remained the mainstay in the anti-malaria effort to the end of the colonial period. Both the biomedical approach of quinine prophylaxis and the scientific anti-mosquito approach of Ross—which the Japanese colonial government modified to fit its civilizing mission, as Ku has pointed out—relied heavily on the state’s exploitation of a highly centralized administrative structure for implementation, and they succeeded in reducing malaria mortality—from 10,562 in 1906 to 3,716 in 1937.
It is significant to point out that during the colonial period, there had been a gradual decline in epidemic and endemic diseases and a steady increase in deaths resulting from chronic diseases or congenital conditions. This was particularly the case after 1930, and this development suggests that Taiwan went through the early stage of the epidemiological transition. Some infectious diseases were brought under control, thanks largely to the success of vaccination policies and despite some resistance from the local populace. General health improvements, education, and the institutionalization of medical practices also all contributed to the successful management of a number of prevalent infectious diseases. From the perspective of the colonial state, it had acted decisively and coercively when necessary to overcome the “inability” of the local communities to embrace the benefits of modern biomedicine and public health.
Health and the Nationalist State before 1945
In addition to inheriting the Japanese anti-malaria legacy—especially the proactive role played by the state, the reliance on biomedical techniques, and the emerging epidemiological transition—the Nationalist government also brought with it from the mainland its experience in constructing a health infrastructure and in combating common infectious and parasitic diseases. What is significant is that the Nationalists were also very much concerned with the authority and role of the state in health matters (although their raison d’être was certainly different from that of the Japanese colonial state) and they too subscribed to a biomedical solution to health and disease problems. In order to evaluate the Nationalist anti-malaria efforts in the postwar period, we have to examine the role of the Nationalist state in the development of health policies on the mainland after their ascent to power in 1928 and the experience they thereby brought with them to Taiwan.
When the Nationalists took power on the mainland, it committed itself to building a modern state that would achieve national strengthening and modernization. To accomplish this goal, the Nationalist party-state claimed for itself a tutelary responsibility in the nation-building effort and reserved for the state the unquestioned authority in creating and directing agencies and organizations capable of implementing the new national agenda for social, economic, educational, technological, and military reconstruction. Such a proactive approach in state-building had significant consequences for health developments. For Nationalist leaders, a physically weak population retarded economic development, and made China more vulnerable to, and less capable of resisting, foreign aggression. At the same time, it was believed that the provision of state-sponsored health care would improve the people’s livelihood which in turn would serve as a conduit to gain support from the people for the regime, and thereby secure political control. Thus, insisting that the people’s health was vital to the nation’s survival, the Nationalist party-state defined both the concept of individual health and the role of the state in developing policies and institutions designed to conserve and promote the citizens’ physical health. In accordance with its understanding of state-enforced modernization, the government professed its responsibility to develop a health care system that would provide relief for the largest number of people and state medicine (gongyi) emerged as the chosen model.
The establishment of the Ministry of Health in 1928 marked the beginning of a long process of setting up central health administrative and technical agencies as well as a hierarchy of health organizations that culminated in the promulgation of a state medical system in 1940. The Ministry assumed direct control over the medical and public health functions of the state, working through or co-operating with a number of central technical and research agencies. The hierarchy of health agencies under the Ministry’s jurisdiction included the health departments of provinces and special municipalities, although the Nationalist government’s inability to control the country as a whole during its mainland days meant that the extent of the Ministry’s direct authority was actually quite limited. In many cases, it was confined to defining principles of macro-policy which might or might not be followed by local jurisdictions. At the xian (county) and sub- xian levels, the government envisioned a three-tiered structure that would include county health centers, qu (district) health stations, and xiang (village) health sub-stations. Initially, such a structure was introduced only in certain demonstration areas, but in 1940, in the midst of the war against Japan, the government officially promulgated regulations for the establishment of the hierarchy of health services, and added the baojia (a collective neighborhood system of civil control) health worker as the lowest level health provider. Except for limited areas in unoccupied China, this plan remained largely theoretical as the war seriously disrupted state medicine programs. Despite governmental attempts to revive the plan nationwide in 1947, the collapse of the Nationalists soon afterwards derailed further efforts on the mainland.
From the beginning, the Nationalist government embraced science in its effort to modernize China, attracted by the perceived potential of modern science for China’s strengthening and modernization. Not surprisingly, it advocated scientific medicine and essentially supported the position of modern medical professionals that Western biomedicine should be the standard for the state health system that it planned to construct. The fact that these professionals dominated the health services established after 1928 facilitated the introduction of measures that would strengthen the structural superiority of biomedicine: the founding of medical schools based on scientific medicine, the establishment of modern health agencies and organizations, and the introduction of a system of physician licensure in accordance with biomedical knowledge and practice, thereby affirming the legal position of modern medical practitioners. Major governmental agencies concerned with biomedical research and technology included the Central Field Health Station, the central headquarters for technical aspects of public health research and field application; the Central Hygienic Laboratory which conducted chemical and pharmaceutical analysis, and bacteriological and pathological examinations and research; and the National Epidemic Prevention Bureau, responsible for research and production of sera and vaccines. In areas under its control, the government launched mass inoculation campaigns in the 1930s against smallpox, cholera, typhoid, and diphtheria, providing free vaccines to various local health authorities. In short, most medical leaders in the Nationalist government firmly believed in the validity of Western biomedicine and technology, and were unhesitant in promoting its use despite the still limited availability of, as well as accessibility to, prophylactic vaccinations and Western medicines for the general population, the majority of whom still relied on indigenous medicine for relief.
Nationalist Anti-malaria Efforts in Mainland China
Before relocating to Taiwan, the Nationalist government tried to introduce an array of organized public health activities, ranging from sanitation, communicable disease control and the collection of vital statistics, to industrial hygiene and maternal and child health. These activities were designed to control some of the most prevalent diseases, including tuberculosis, cholera, schistosomiasis, hookworm, smallpox, kala-azar, and malaria. Beginning in 1929, the Nationalists collaborated with the League of Nations Health Organization on various health matters, one of which was malaria control. In 1931, a League malariologist, Professor Mihai Ciuca, was in China to help set up a Department of Parasitology to focus on the study and control of malaria in the Central Field Health Station. With the government’s support, Professor Ciuca conducted the first major scientific study of malaria along the lower and middle Yangzi Valley. The Central Field Health Station and Chinese scientists also conducted studies in other parts of the country, while the Malaria Commission of the League provided advice to the government on methods of malaria control.
The Nationalist anti-malaria effort faced a number of obstacles including the absence not only of national planning and co-ordination, but also a long-term strategy, funds, trained personnel, and sufficient scientific data. With the limited resources that were available, the Ministry of Health compiled epidemiologic data and conducted field investigations, while anti-malaria stations were established in a few health demonstration sites that had been set up to experiment with modern health practices. Control measures such as the application of Paris green and the breeding of larvae-eating fish were introduced, and quinine was administered to patients in a number of clinics to study the effectiveness of anti-malarials. The anti-malaria strategy was essentially biomedical with limited vector control since large-scale environmental and sanitation improvements proved to be too costly and difficult to carry out when the Nationalists did not have control over many local jurisdictions. In specific areas, the government tried to register the population for testing, and those succumbing to the disease would be treated with anti-malarials. The malaria infection rate remained high, however, throughout the 1930s and 1940s. In 1933, one county alone in Yunnan province reported 30,000 malaria fatalities, and in the 1940s, the mortality rate for malaria in the country as a whole was estimated to be about 1%. A valuable lesson for future anti-malaria work was the attempt to combine anti-malaria activities with the work in the regular hierarchy of health services, or at least in the few health centers and stations that had been set up at that time.
With the outbreak of the war against Japan and the retreat of the Nationalists to the interior, the problem of malaria control became even more acute since the disease was endemic in several of the interior provinces and many refugees from the coast had no immunity to it. A high toll of human lives was exacted as a result. The Malaria Laboratory of the National Institute of Health (formerly the Central Field Health Station) began control programs in several demonstrations areas in and near Chongqing—the wartime capital—while the government also funded two relatively large-scale programs in the provinces of Guizhou and Yunnan. Unfortunately, the unsettled conditions, the massive movements of troops and people, and the exigencies of the war made it virtually impossible for the government to sustain any long-term anti-malaria effort.
Health and the Nationalist State in Taiwan
When the Nationalist government reclaimed Taiwan after the Japanese surrender, they did not have to start from scratch in their efforts to establish modern health services, and there were important continuities in medical and public health practices. There was also a population that had become generally accustomed to Western biomedicine. Because of the breakdown of the health structure during the last years of the Japanese colonial administration and the destruction of medical facilities during the war, Nationalist health leaders were confronted with serious health problems on the island. The mortality rate of malaria had risen to 10 per 10,000 people in 1942 from just slightly over 7 per 10,000 in 1937. In 1945, one-sixth of the total population of 7.5 million were infected with malaria, and in 1946, there were outbreaks of smallpox in Taibei and Taidong, and cholera in Jilong (Keelung). The Nationalist government provided funds for the reconstruction of health facilities and communicable disease control. A most important step was the Nationalist government’s abolition of the Japanese system of placing health matters under the jurisdiction of police departments and the conversion of the health sections of former colonial police departments into health centers. With the formal establishment of the Taiwan provincial government in May 1947, the provincial health department, under the direction of the central government, began to assume the responsibility of developing an island-wide health system.
This process was accelerated after the Nationalist government had established itself on the island in 1950 with the professed objective of building Taiwan into a “Three People’s Principles model province.” The Ministry of Health had been greatly reduced in size and authority, having been downsized to a department in the Ministry of the Interior, and only three of its subordinate agencies were transferred to Taiwan. The provincial health department, however, expanded its jurisdiction and public health functions in the next decade, including the supervision of the establishment of a hierarchy of health organizations in the xian. With the formal promulgation of the organizational plan for xian health services by the Legislative Yuan in 1952, the health hierarchy was formally established, a structure which essentially replicated the threefold division of xian health services introduced previously in the mainland. In Taiwan, health centers were established at the xian or city level; health stations served at the qu, xiang, or town level; and health rooms provided services in villages, especially in mountainous and isolated areas. The number of health centers increased from 16 in 1947 to 22 in 1961 when they were expanded into health bureaus to meet the expanded scope of health activities. These bureaus directly supervised the activities of 361 health stations and 168 health rooms throughout the island. These health stations and health rooms proved to be most important in the implementation of public health measures and supervision of the population in health matters. They served both clinical and preventive functions providing curative clinics, child and maternal care, school-based health education, and public health campaigns, as well as collecting vital statistics, and working with the community to combat communicable diseases. To some extent, this system seemed quite similar to the system of medical surveillance of the Japanese colonial sanitary police; certainly, both were ubiquitous and quite capable of mobilizing and supervising the community. But one must remember the important continuity of the Nationalist effort—the state had actually succeeded in establishing a health structure that it had tried in vain to establish on the mainland.
The national health system was staffed by doctors trained in biomedicine, including those who had moved from the mainland as well as those trained in the Japanese colonial medical system. In fact, in 1946, there were nearly 3,000 physicians with Western training in Taiwan, and modern public health and government-sponsored health care services were available throughout the hierarchy of health organizations discussed above. The hegemony of biomedicine extended to medical education: all five major medical colleges established before 1970 offered training in Western biomedicine. Biomedical research was conducted in the medical colleges and government-sponsored research agencies and institutes, often with notable results.
Foreign organizations also helped to promote biomedicine and research. The Rockefeller Foundation, which had played such a critical role in the promotion and development of biomedicine in China since the 1910s, had terminated its programs on the mainland after the communist victory, but it continued to offer limited support to medical education and the training of health personnel in Taiwan. The Taiwan University College of Medicine, for instance, benefited from the largess of the China Medical Board, established in 1914 by the Rockefeller Foundation, in the construction of much needed buildings and facilities. The American Bureau for Medical Aid to China, which had donated medical equipment and medicines to China during the Sino-Japanese war, supported some study fellowships for Chinese medical graduates from Taiwan, and provided funds for health education and school health programs.
Although the government approved the founding of the Chinese Medical College for the training of practitioners in Chinese medicine in 1958, it failed to provide any financial support, and it was only in the 1970s that the school gradually achieved steady growth and development. It is important to note that the Japanese colonial government before 1945 had systematically suppressed Chinese medicine, and that legacy, coupled with the Nationalist government’s embrace of Western biomedicine, contributed to the continued hegemonic status of Western biomedicine in Taiwan.
The Nationalist government’s rationale and role in the creation of such a system cannot be overstated. The objective of creating a physically strong population in the Nationalists’ continued struggle against the communists as well as the desire to develop a viable alternative to communism helped to encourage government initiatives in health promotion and conservation. State medicine was still the professed objective of the government, and the belief that an environment favorable to health improvement was essential to economic growth and prosperity continued to inform Nationalist health policies. The rapid economic growth and social changes in the 1960s as well as the government’s desire to emphasize an economic development strategy that was highly driven by technology necessitated the expansion of the infrastructure of education and health care for the population. To anticipate health needs and to further centralize health control under the central government, the health department in the Ministry of Interior was abolished, replaced by a National Health Administration under the Legislative Yuan in March 1971, and the array of public health agencies and activities expanded under central direction. From the mainland to Taiwan, the Nationalist party-state’s role remained critical in defining the parameters of health development, the formulation and implementation of policies, and the mobilization of resources. The state medical system, especially the hierarchy of health services, in fact contributed significantly to the government’s anti-malaria effort and other health campaigns.
For the development of organized public health, the government continued to rely on biomedicine and the same strategies for scientific development they had adopted on the mainland. Continuing the biomedical and technological model of disease control and eradication, the government initiated island-wide vaccination campaigns against cholera, poliomyelitis, diphtheria, pertussis, and Japanese encephalitis. Epidemiological investigations and biotechnical methods of blood sampling, for instance, provided data for the control of parasitic diseases such as hookworm and malaria. The Nationalist government also received foreign support for its public health activities. As noted, the American Bureau for Medical Aid to China provided financial support for health education and school health programs. In the early 1950s, the United Nations International Children’s Emergency Fund (UNICEF) contributed funding for public health activities related to maternal and child health—two areas that were of vital concern to the Nationalist government in their attempt to build a strong state—nutritional improvements, and mass vaccinations. In 1952, an agreement with WHO also resulted in financial and technical assistance in campaigns against tuberculosis and venereal diseases as well as support for nursing education. These developments reinforced the importance of the biomedical and technological model of disease control. In fact, when dichloro-diphenyl-trichloroethane (DDT) was introduced in the 1940s, Taiwan was one of the sites where the chemical was tested for its effectiveness as a means of malaria control. The hegemony of DDT soon eclipsed other methods of malaria control and eradication.
The Role of the Rockefeller Foundation
The Rockefeller Foundation was to play an important role in shaping the Nationalist government’s approach in its anti-malaria efforts. The Foundation, which had played a critical role in the development of modern medicine and medical education in China since the 1910s, became directly involved in the anti-malaria effort during the Sino-Japanese war. Beginning in 1940, with the support of the Nationalist government, it organized a malaria study program in Lashio at the China-Burma border, focusing on conditions in an area which had emerged as the major supply route of materials and provisions for the beleaguered Chinese government. A malaria laboratory was set up to collect data on local anopheles mosquitoes and the incidence of malaria. The work had to be terminated two years later, however, when Japanese advances threatened the laboratory, which was then evacuated to Chongqing. After the war, even in the midst of the uncertainty of the postwar struggle between the Nationalists and Communists, the Foundation hoped to revive some of its health activities in eastern China. It dispatched Foundation representatives Dr. Robert B. Watson, Dr. J. Harland Paul, and J.C. Carter to China to develop health services with malaria control programs. In 1946, it discussed with the Nationalist government the possibility of selecting two field areas for malaria study, one in Zhejiang province, and one in Taiwan. Political instability, however, caused the foundation to scale back its potential commitments. The Zhejiang project never materialized while the Taiwan research center was launched in 1946 with the aim of conducting a five-year program to collect data and train personnel.
The research center in Taiwan, a result of the co-operation between the Nationalist government, the Taiwan Provincial Department of Health, and the Rockefeller Foundation, selected three sites as field stations: Chaozhou in the south, Jilong in the north, and Shuili in central Taiwan. In 1948, the research center was formally named the Taiwan Malaria Research Institute (TMRI) and became a division of the Provincial Department of Health, but personnel from the Foundation continued their direct involvement in the program. The epidemiological data on Anopheles sinensis and A. minimus (the two chief vectors in Taiwan) collected by the TMRI would prove vital to the eradication campaign in 1951. At the same time, the testing of anti-malaria drugs was also initiated among villagers.
The collection of malariological data, demonstration of control measures, and the training of personnel reflected the main concerns of the Foundation’s work at that time. During the interwar years, the Foundation had been at the forefront of working with various governments (including China) to develop demonstration programs for disease control or eradication. By the 1930s, the Foundation developed a strategy that emphasized epidemiological studies and the use of civil and sanitary engineering methods in the control of malaria. Yet this strategy would soon be enhanced and to a significant extent superseded by the adoption of a technological approach. As DDT emerged as a potentially powerful technology in disease control in the early 1940s, the Foundation began to embrace it as the central element of its anti-malaria campaigns.
During the war, the Foundation had worked with the Committee on Medical Research of the U.S. wartime office of Scientific Research and Development to test the insecticidal qualities of DDT, and in 1944, it experimented with the application of DDT in a malaria control program in southern Italy. The success of the experiment led to widespread use of DDT by the U.S. military in the Pacific region. In early 1945, the U.S. government, with the approval of Mexico, invited the Rockefeller Foundation to launch experimental malaria control work with DDT. By 1948, bolstered by the successes of DDT technology, the Foundation initiated limited DDT residual spraying of houses in small villages near Chaozhou and Jilong in Taiwan, and the spraying program was expanded in 1949.
The Foundation’s work was, however, terminated at the end of 1949, but other organizations would co-operate with the Nationalist government to continue the anti-malaria effort. In all these activities, the Foundation was operating within the model of developing, adopting, and diffusing technological innovations, a model that marked DDT’s rise to prominence in the postwar period when the hegemonic position of the United States made it possible for many other countries to follow this technological model of disease control and eradication, with WHO providing the leadership in a global malaria eradication program.
Global Malaria Eradication
WHO was one of the many international organizations formed after World War II to provide relief and development aid to war-torn and developing countries. It owed its origin to a joint proposal presented to the United Nations Conference on International Organization in San Francisco in April 1945 by Dr. Szeming Sze, a Chinese representative, and Dr. Geraldo da Paula Souza, a Brazilian representative. Its objective was to co-ordinate and direct international health work, a function similar to that of the League of Nations Health Organization, although WHO, while working closely with UNICEF and other UN agencies, was independent of the UN. During the first two decades of its existence WHO was dominated by a few Western industrialized countries and largely confined its work to purely technical matters, ignoring the broader issues of socio-economic development. However during this time it did also formulate several major campaigns against specific infectious diseases that affected huge populations in the developing world such as yaws, tuberculosis, and malaria.
WHO’s malaria control projects in various parts of the world after the war had provided the testing grounds for residual spraying and other control measures. By 1946, large-scale control programs that relied exclusively on house spraying with DDT began in Ceylon, India, and Venezuela. When the Rockefeller Foundation began its DDT spraying experiments in Taiwan in 1948, many international health authorities were persuaded of the usefulness of the chemical’s role in malaria eradication. In 1954, the Pan American Sanitation Bureau called for a shift from malaria control to malaria eradication throughout the Americas. In January 1955, Pakistan resolved to eradicate malaria in five years. In May that same year, WHO decided to move from malaria control to an ambitious program of global malaria eradication. According to WHO, malaria eradication meant “the ending of the transmission of malaria and the elimination of the reservoir of infective cases in a campaign limited in time.” As such it did not imply vector eradication; rather, the aim was to break the cycle of transmission for three years, so that thereafter anti-mosquito measures can be discontinued, leaving the vector anophelines in existence but without the possibility of becoming infected.
The eradication strategy would involve a preparatory phase of a few years in which epidemiological data would be collected and evaluated, and operational techniques tested. The attack phase that followed would focus on DDT spraying in order to interrupt transmission. If that proved to be successful, the consolidation phase, in which any residual or imported cases would be identified and eliminated, would begin. That would be followed by the maintenance phase, during which a sound surveillance system would be put in place to prevent the reintroduction of infection; this would mark the completion of the eradication program.
For the Nationalist government in Taiwan, the program was extremely attractive because the Japanese colonial government had developed an anti-malaria structure to suppress the disease, although the capacity of this structure had been seriously damaged as a result of the war. At the same time, the Rockefeller Foundation had already laid the groundwork for a broader anti-malaria program during the immediate postwar years. In fact, the period from 1946 to the Foundation’s withdrawal from the mainland in 1949 was later considered to be part of the preparatory phase (officially from 1946 to 1951) of the entire anti-malaria program that led to the eradication of the disease in Taiwan in 1965. The faith in biomedicine and technology, already present in the Nationalist approach to scientific and public health constructions, reinforced the modernist ideology of “progress through technology” in the postwar era.
Political factors also proved to be important. After relocating to Taiwan, the Nationalist government was anxious to undertake rehabilitation and reconstruction efforts that would ensure stability on the island as well as mobilize the population to build a vibrant society and strong economy. The declaration of martial law in May 1949 by the Nationalist government allowed the state to introduce measures deemed essential to pursuing these objectives. Indeed, state intervention proved critical in providing policy direction and funding for agricultural reforms and industrialization. Economic growth was accompanied by rising standards of living and the construction of an infrastructure of railroads, roads, educational institutions, and public health facilities. Living conditions were improved with government-promoted, island-wide health campaigns against such diseases as cholera, polio, diphtheria, smallpox, tuberculosis, and plague. Plague was eradicated in 1948, and the last case of smallpox was reported in 1955. As the government pointed out, eradication of malaria would mean an improvement of people’s health, elimination of suffering, and increase of production by the people in agriculture or industry. Collateral benefits may be measured in general public health uplift. To the Nationalist government, Taiwan’s success was crucial in demonstrating a real alternative to communism on the mainland.
Yet malaria eradication was costly, requiring large quantities of materials and supplies that the government could not afford. Moreover, personnel had to be trained and paid, and an operational structure put in place to ensure adequat e spatial and temporal coverage of DDT spraying. Postcolonial struggles in many parts of the world also created political and social instability making it difficult for sustained health campaigns to be developed. Fortunately for the Nationalist government, the end of colonialism in Taiwan did not lead to the kind of political turmoil experienced by many former colonies in Africa or Southeast Asia. Moreover, the problem of funding was solved when development agencies in the United States and other international organizations were ready and willing to assume the lion’s share of the cost of anti-malaria campaigns, not only in Taiwan, but in many parts of the world.
Postcolonialism and Malaria Eradication in Taiwan
Postwar U.S. foreign policy had, to a significant extent, been informed by the desire to encourage economic recovery in Europe and Asia as a means of promoting political stability, forestalling the rise of communist challenges, and resisting Soviet pressures. Before 1947, enormous amounts of aid had been channeled through the United Nations Relief and Rehabilitation Agency (UNRRA); in 1947, funds for the reconstruction of infrastructure and industries were provided through the Marshall Plan for Western Europe and other programs for Japan. These activities constituted a part of the construction of a multilateral world economy that would allow the unobstructed movement of capital and labor, as well as the realignment of the balance of power in Europe and Asia. In this new order, the developing world played important roles: it was the exporter of raw materials to the U.S. (which encouraged U.S. investment), and a market for European goods (while U.S. exports went to Europe). The productivity of underdeveloped and developing countries (many of them in tropical regions) became an important link in this new economy, and the improvement of their populations’ health was therefore vital.
Such concerns were expressed by U.S. policy makers, including Secretary of State George Marshall who, in 1948, listed the benefits of conquering tropic diseases: “the great increase in the production of food and raw materials, the stimulus to world trade, and above all the improvement in living conditions.” These are all seen as desirable goals in the new definition of development which coincided with U.S. postwar political and economic interests. Moreover, cold war politics made the rapid construction of a revitalized global economy led by the U.S. particularly urgent. Highly visible campaigns against common diseases, such as the malaria eradication programs, could help to win popular support for local governments. In 1956, the International Development Advisory Board noted that the present governments of India, Thailand, the Philippines, and Indonesia among others, have undertaken malaria programs as a major element of their efforts to generate a sense of social progress, and build their political strength. Indeed, broader political and economic concerns helped to encourage the push for global malaria eradication.
Taiwan and South Korea proved to be of major importance in U.S. calculations of power alignment in Asia. They would “serve as models of noncommunist, politically stable and economically successful societies operating with free-market institutions within the U.S. sphere of influence.” Between 1951 and 1968 the Nationalists received U.S.$1.5 million in aid, as well as a large number of U.S. advisors and technical experts to support the transformation of Taiwan. U.S. economic aid to Taiwan included funding for projects in agriculture, industry and mining, transportation, health and sanitation, education, public administration, social welfare and housing. In short, U.S. aid did much to keep military spending down, and contributed to the building of infrastructure, the provision of human services, and agricultural and industrial development. At the same time, the Nationalist government introduced agricultural reforms that included rent reduction and land distribution; established basic, import-substitution industries; and improved living conditions through housing development and public health campaigns. In these developments, the Sino-American Joint Commission on Rural Reconstruction (JCRR) emerged as a major player. This was an agency created by the U.S. Congress in 1948 to assist in China’s agricultural development,
When the Rockefeller Foundation ended its malaria work in Taiwan in late 1949, Robert B. Watson, the Foundation’s representative responsible for closing down the program, expressed the hope that the Foundation’s work would be taken over by the JCRR., In August 1949, JCRR moved its headquarters from Guangzhou (Canton) to Taiwan and, as Watson had hoped, played a vital role in Taiwan’s postwar reconstruction, including the development of the anti-malaria campaign. Unlike “vertical” campaigns— with their vertically organized structures not supported by clinic-based primary health care systems—launched against malaria (and other diseases such as sleeping sickness and yaws) in many other countries, the anti-malaria program in Taiwan developed as a “horizontal” program, thanks to the initiation of concurrent programs by the government that addressed a broad spectrum of public health issues as well as the building of a health infrastructure. The JCRR assisted in the establishment of a health network that included 22 county health centers and a health station in each of the 356 townships by the end of the preparatory phase of the anti-malaria campaign in 1951. Moreover, many of the recently reopened anti-malaria stations—144 by the end of 1951—were gradually incorporated into the township health stations. This comprehensive health network provided both curative and preventive services and proved critical to the next phase of the malaria eradication campaign that focused on DDT spraying.
In October 1951, representatives from the Ministry of Health, Taiwan Provincial Department of Health, TMRI, WHO, JCRR, and the U.S. International Co-operation Administration met to formulate a four-year attack program that began as a control measure to interrupt the chain of malaria transmission, with the ultimate objective of malaria eradication. Pilot projects were set up to test DDT residual spraying in Qizhang of Gaoxiong county and Chaozhou of Pingdong county in southern Taiwan. Island-wide spraying took place from May to September in 1952, as did a program of collection and analysis of entomological and epidemiological data. The process and results were evaluated to determine the quantities of labor and chemicals needed for specific tasks. The communities involved were informed of the procedures and their participation became an integral part of the projects. The former anti-malaria stations, which had been incorporated into local health stations, changed their primary function from that of administering anti-malaria drugs to supervising spraying operations and other insect control activities, while continuing with their regular medical and public health functions. The success of these projects encouraged the government to extend the four-year program for two more years so that the entire attack phase would end in 1957. Besides funding from the central and local governments and WHO, additional financial support came from the U.S. Foreign Operations Administration and the Council for U.S. Aid.
Island-wide DDT spraying ended in 1957. Maximum coverage, in terms of population, was reached between 1954 and 1957, with an average of 5 to 6 million people per year affected directly by spraying. The government also began to manufacture its own supply of DDT, sprayers, and accessories, many of them modified from foreign models to adapt to local conditions. Labor for the anti-malaria work was drawn from personnel in the anti-malaria stations as well as the regular health network. While TMRI provided the technical expertise and planning, it also, together with WHO, helped to train county and municipal supervisors as well as township supervisors and squad leaders. As the training structure gradually decentralized, the supervisors, and later, basic level personnel, assumed the responsibility of providing instruction and operational training. The existence of personnel with basic skills and their effective economic use ensured the success of the attack phase and constituted the backbone of the surveillance system later. Significantly, the military was actively involved in the entire campaign, working closely with TMRI through liaison officers who were partly funded by JCRR.
Pre-1949 legacies proved to be useful in the DDT spraying program. Epidemiological data collected by the Rockefeller Foundation’s malaria projects and TMRI revealed important clues to understanding the activities of the mosquito vectors and residual spraying could therefore adjust to their different feeding and resting habits. Moreover, the Nationalist government also inherited the household system imposed on the population by the Japanese colonial government before 1945, which, with modifications, served as a means to collect vital information about the population, thereby facilitating the mobilization and education of the communities during the anti-malaria campaign. Community participation proved to be extremely beneficial as it helped to ease the population’s anxiety about the chemical as well as provide feedback about the results and possible side effects of spraying. The success of the attack phase was revealed in the dramatic decline in the number of deaths caused by malaria—from about 1.2 million in 1951 to 676 in 1957. In 1952, malaria ranked 10th among the 10 leading causes of death in Taiwan, but from 1953 to 1958, it had disappeared from this top 10 list altogether.
By the end of 1957, TMRI and WHO entered into another agreement to carry out the final stage of malaria eradication. The agreement made it clear that since control had been achieved, it was paramount that the few remaining cases should be eliminated in order to prevent a potential epidemic, as the people of Taiwan had lost their immunity from the disease due to the success of residual spraying since 1952. Moreover, there had not been the development of resistance to DDT among the local anopheline species. Thus, the eradication scheme required limited residual spraying as well as the implementation of a malaria surveillance structure to detect all remaining malaria cases.
This final stage—the consolidation phase of the campaign—lasted from 1957 to 1965. While the government continued to assume all regular operational costs, WHO and the U.S. International Co-operation Administration continued to provide financial support, especially for specialized personnel. An island-wide surveillance system was gradually set up before and during the consolidation process to monitor the population for any new cases, to investigate their causes, and to prevent any spread of the disease. Mobile malaria detection teams trained in microscopy, and blood examinations were organized. The government also created rural, township, and municipal malaria vigilance units to detect and report new cases, carry out blood examination, and distribute anti-malaria drugs. During this period, surveys and mosquito collection were conducted in collection stations, while DDT spraying continued in residual areas where transmission was still a problem. The last indigenous case of Plasmodium falciparum occurred in July 1961, that of P. vivax in December 1961, and that of P. malariae in November 1962. But there was still the potential problem of imported cases and strict regulations were introduced to prevent new cases of infection from entering Taiwan from abroad.
At the end of 1964, an investigative team from WHO visited Taiwan and determined that the Nationalist’s campaign had been successful. The following year, WHO formally declared Taiwan to be free of malaria. The island’s anti-malaria efforts therefore entered the maintenance phase in which vigilance against infection would continue and measures to prevent the re-introduction of malaria would be enforced. As a result of the success of the campaign, TMRI was dismantled in late 1974, and reorganized into the Taiwan Communicable Disease Research Institute, with malaria work continuing in a small unit within the agency.
Conclusion
This chapter has sought to put the malaria eradication programs in Taiwan in the context of the development of health programs and infrastructure in the Nationalist state—both in the mainland and in Taiwan—as well as in a global historical perspective. Not only pre- and post-1949 developments have been noted, but also the importance of political, economic, and ideological factors—both within and outside China—that helped to shape the rationale, directions, and evolution of the campaigns. I have highlighted the dominant role played by the state—the Japanese colonial state as well as the Nationalist state—and the consequences of their respective visions for the island.
For the Nationalists in particular, their role in orchestrating the creation of a health care system as well as the development of organized public health activities based on their understanding of how improvements of the population’s health could contribute to national strengthening and modernization was critical, both before and after 1949. During their years on the mainland, the Nationalist government was never able to control the entire country, and political stability was absent. In order for any malaria control or eradication project to succeed, there has to be a stable government with the will, determination, and authority to provide full backing to implement necessary measures in all phases of the anti-malaria campaign. It was only after the Nationalist government established itself in Taiwan that a program to control or eradicate malaria became feasible. The hierarchy of health services that constituted the foundation of the Nationalist’s plan for state medicine on the mainland, and which was successfully established in Taiwan, proved to be essential in the island-wide campaign. It was the government’s ability to direct and co-ordinate health operations at the micro level as well as provide both preventive and curative services to deal with health problems that ensured the success of the anti-malaria and other public health efforts; this was something they had not been able to achieve on the mainland. In short, the full backing of the government was vital not only in initiating the project, but also in sustaining the course of action throughout the different phases of the campaign. Yet, the participation and co-operation of the population—a sizable portion of them had experienced the implementation of health measures under the Japanese—was also critical and contributed to the relatively smooth execution of plans.
Health developments under the Nationalists had benefited from both financial and technical support from international organizations such as WHO and foreign aid from countries such as the U.S. While in the mainland, the decision of the Nationalists to seek support from the League of Nations Health Organization in the late 1920s paved the way for collaboration with Western powers in efforts to modernize China. Of course, health was only one aspect of the multilevel and multinational collaborative relationships that the Nationalist government established with the League, the Rockefeller Foundation, and government agencies of various countries in an array of nation-building efforts that included finance, transportation, water conservancy, industry, agriculture, and the military. In health matters, the models of scientific medicine and state medicine were embraced by health leaders and government officials who were inspired by the transformative and modernizing power of science, but who also recognized the crucial role that foreign financial and technical aid and advice could play in China’s modernization.
In the postwar period, the Nationalist government continued to benefit from the largess of international aid agencies and philanthropic organizations. The work of the Rockefeller Foundation was important in the early stage of the anti-malaria efforts, especially in epidemiological research, while the newly established WHO and development agencies of the UN also contributed to the development and implementation of health programs in Taiwan. Above all, the role played by the emerging hegemonic political-economic order under the U.S. in Asia became critical, as U.S. aid did much to keep military spending down, and contributed to the building of infrastructure, the provision of human services, the development of agriculture and industry, and certainly, the improvement of health through campaigns against diseases.
Yet it should be remembered that the Nationalist government was able to take advantage of the aid and services as well as technology transfer because it had emphasized the construction of educational and health infrastructure and was able to utilize the medical knowledge of those experts who accompanied the Nationalists to Taiwan as well as those who were already on the island. During the period under discussion, the government had, through agricultural reforms, industrialization, improvements of education and health, as well as more equitable distribution of social resources, contributed to higher standards of living and better living conditions. Its dominant role in these and other developments certainly affected anti-malaria efforts. With the strategy of malaria eradication clearly defined by WHO and sufficient funds from both international and domestic sources, the government succeeded in pursuing and achieving the objectives of the anti-malaria campaign.
All these factors—combined the government’s continued commitment to a policy of embracing science in its push toward modernization and the building of a real alternative to communism on the mainland—provided a milieu favorable to the adoption of biomedical technology in the fight against malaria and other diseases. The relatively small size of the island allowed for systematic island-wide DDT spraying, and facilitated surveillance and control after the attack phase ended. Taiwan’s experience seemed to confirm that the strategy of eradication, as envisioned by WHO, was practical only when a combination of conditions such as those that existed in postwar Taiwan were present. When similar conditions did not exist, and when malaria eradication campaigns floundered in other parts of the world, many health leaders, recognizing the limitations of the malaria eradication strategy, finally abandoned the ambitions of global malaria eradication in the late 1960s, and strategies of control were again promoted for countries still struggling against this deadly disease.