Darwin H Stapleton. Disease, Colonialism, and the State: Malaria in Modern East Asian History. Ka-che Yip. Aberdeen, Hong Kong University Press, 2009.
Malaria in twentieth century East Asia has had much the same career as elsewhere on the planet: it has been studied, attacked, partially mastered, but never overcome. For about one-third of the century (approximately 1920-1955) the Rockefeller philanthropies grappled with malaria in endemic areas (the major exceptions being the Soviet Union and Africa) and had their successes, possibly more successes than most other institutions and organizations. While they did not vanquish the foe, the Rockefeller anti-malaria workers made strategic choices and engaged with important problems that bear consideration not only for better understanding the continuing fight against malaria in East Asia, but also for better understanding the globalization of public health.
This chapter will begin with a review of the founding and history of the Rockefeller organizations that played a role in the development of public health in East Asia, and will then examine the Foundation’s work in particular areas. John D. Rockefeller Sr. (1839-1937), the great American capitalist and philanthropist, created several nonprofit organizations whose focus included public health. He began in 1901 by founding the Rockefeller Institute for Medical Research (now Rockefeller University) in New York City to carry out fundamental research in the biomedical field. Among the Institute’s many functions, it served as an international center for advanced training in public health research, hosting researchers and practitioners in its advanced laboratories for periods ranging from just a few weeks to two or three years.
In 1909 the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease was established, ostensibly for the purpose identified in its title and aimed specifically at the southern states of the United States. But the widespread campaign, which focused on grassroots projects, actually attempted to promote improved sanitation practices beyond those necessary to eradicate hookworm (more formally known as ankylostomiasis), and the Commission’s officers quickly developed a public health strategy that they believed could be globally effective. In 1913 the Commission was formally transformed into an international organization, and in 1916 it was renamed the International Health Board (IHB). As the first truly international public health organization the IHB attempted to create a co-operative corps of sanitation workers with similar levels of education and sets of skills throughout the world so that co-ordinated projects of disease control and eradication would be possible.
In 1913, the same year that he established the IHB, John D. Rockefeller created his largest and most famous instrument of philanthropy, the Rockefeller Foundation (RF), which was headquartered in New York City, as was the IHB. Among its several major program areas was medical education, and within a few years the Foundation became the largest source of funding for new programs in advanced public health training in the world. Focusing in its first years on the United States, the Rockefeller Foundation helped to create great public health schools at Johns Hopkins University (Baltimore, Maryland) and Harvard University (Cambridge, Massachusetts), which for decades were the primary training centers for Rockefeller field workers in malaria and public health in general.
Importantly for these considerations, the medical interests of the Rockefeller philanthropies in East Asia were delegated in part to an organization established in 1914 and originally subordinate to the foundation, the China Medical Board (CMB). The CMB began its work by investigating thoroughly the situation of Western-style medical research and education in China, which was largely the province of missionary organizations, and concluded that there was need for a center of excellence similar to the Rockefeller Institute for Medical Research, but which would include a medical school, nursing school, and a public health unit. In 1918 the CMB opened the Peking Union Medical College (PUMC), formally dedicated in 1921, which quickly took on the role of training an elite corps of Chinese medical researchers, practitioners, and educators.
In 1928 a reorganization of the Rockefeller philanthropies resulted in the Rockefeller Foundation absorbing the IHB, which was renamed the International Health Division (IHD). At the same time the China Medical Board was given its own endowment of $12 million and became a separate organization, though it remained in close collaboration with the Foundation for many years. This reorganization put all of the public health endeavors of the Rockefeller philanthropies under one roof and was intended to establish better co-ordination of educational institutions, training programs and work in the field.
A major project of the Rockefeller philanthropies, underway at the time of the reorganization and not completed for some years, was the founding of a series of public health institutes around the world. Working with the governments of various nations, primarily in eastern and southern Europe, but also in Brazil, India, and Japan, the IHB located institutes in capital cities or other metropolitan centers in order to train public health workers, usually including nurses, in the latest methods of disease identification, detection and prevention. The IHB and later the RF paid for the buildings, furnishings, and scientific equipment of these institutes, on the promise from host governments that they would budget the funds for continuing programs. The new buildings were grand and well-planned, and most of those not destroyed in World War II are still in use in the twenty-first century. However, the governments’ support of continuing programs did not always match the programmatic expectations of the Rockefeller organizations.
At this point let us consider the cardinal features of the Rockefeller public health programs. Although never laid out as a manifesto, the features can be summarized as four concepts: demonstrate, educate, collaborate, and estimate.
Rockefeller Public Health Features: Demonstrate
In the first half of the twentieth century the Rockefeller philanthropies were the wealthiest public health organizations in the world, but they still did not have the resources to undertake full and continuing public health programs in every corner of the globe. Their strategy was to initiate demonstration projects in significant locales that would be so visibly successful that national and local governments would be virtually compelled to take over and continue them.
The idea of local demonstration projects was adopted from the agricultural experimental stations at state universities, established in the United States following the passage of the Morrill Act in 1862. These stations created model farms that promoted improved farming practices. They used a variety of means, including extension agents who took the ideas and accomplishments of the stations into neighboring communities, in order to show off new practices and new technologies. The scope of demonstration work was broad, and included public health elements such as promoting better food and hygiene.
The first broadly based Rockefeller philanthropy, the General Education Board (founded into 1902 to improve education in the American South), brought officers into its staff who were familiar with four decades of agricultural extension work. It probably was not an accident that in 1917 the trustees of the Rockefeller Foundation hired as their first president George Vincent, who had been president of the University of Minnesota, which had one of the premier extension services in the United States.
The Rockefeller organizations adapted this approach to public health work. As they entered nations and colonies throughout the world they tried to create site-specific projects that would show off their new strategies and techniques, often locating their projects near or even in capital cities, so that prominent government officials could easily view their work. In China, for example, PUMC established a public health demonstration project in 1925 in a ward of Beijing. In the Philippines, health demonstration units were established in Laguna and Rizal provinces in 1929 and 1931 respectively, the latter being adjacent to Manila. Field research laboratories and training sites frequently were identified as “stations,” reflecting their conceptual origins in the American extension system.
Rockefeller Public Health Features: Educate
In all phases of their work the Rockefeller public health philanthropies focused on education. At a basic level their anti-malaria campaigns aimed to inform the general public about particular steps they could take to reduce the incidence of the disease, including covering cisterns and other open water containers; sleeping indoors, with mosquito bars and away from farm animals; and permitting insecticidal spraying of their residences.
The philanthropies also wanted to train a generation of public health workers that they hoped would revolutionize health-delivery systems, and therefore raise the global standard of health. Both the permanent public health institutes and transitory stations trained thousands of field workers in basic techniques of disease identification, prophylaxis and remediation. A study published in 1980 suggested, for example, that the “barefoot doctors” program of the Peoples’ Republic of China had its origins in the rural health training programs of the Rockefeller Foundation.
In particular the IHD and later the RF tried to improve the local administration of public health programs by creating nursing schools and nursing training programs. Based on the rather rigid standards of late nineteenth century nursing education in Britain and the United States, the Rockefeller philanthropies strove to create corps of highly-skilled nurses (virtually all of whom were women) who knew the latest Western medical technologies, yet remained handmaidens to Western-trained physicians (virtually all of whom were men). Setting aside the social assumptions behind this system, this Rockefeller initiative may have been one of its greatest contributions to medicine and public health, helping to set up a standardized international educational system for nurses that continues to flourish.
Moving up a narrowing pyramid of education, the Rockefeller philanthropies created a fellowship program that allowed promising students of public health, including people who were already members of national public health bureaucracies, to spend weeks, months, and sometimes several years, in obtaining advanced training. Beginning with a few fellowships offered to Chinese medical students in 1916, this program (which encompassed all areas of Rockefeller activity, not just public health) expanded throughout the 1920s and 1930s: about 2,000 fellowships were awarded in public health and nursing.
Typical fellows already had some training in medicine or public health in their native country (or colony), or were already serving in that country’s health bureaucracy. They were identified as candidates for the fellowship by a Rockefeller officer, usually after consultation with national or colonial leaders, because they appeared to be persons with the ability to play prominent roles in an expanded public health system. Such individuals were proposed to the Rockefeller office in New York or, if they were in Europe, the RF’s Paris field office (which operated with considerable independence), along with a proposed place of study or itinerary of visits. When a fellow was appointed, a substantial stipend covering all travel and living expenses was determined, and a start date was established.
Because Rockefeller officers had extensive connections in public health establishments throughout the United States, Canada, and Europe, it was possible to send these fellows for study at leading public health institutions (usually Johns Hopkins University or Harvard University in the United States), or to intern at model public health projects. Alternatively, or in combination with such study, fellows with malaria interests were given assignments that focused on active field stations: in the United States typical site visits for fellows interested in malaria were the Training Station in Andalusia, Alabama, and the Station for Field Studies in Malaria in Leesburg, Georgia.
Two examples, one from the Philippines and one from China, are illustrative. Dr. Pablo de Jesus had just obtained a medical degree from the University of Philippines (Manila), where he was an instructor, when he was offered a one-year fellowship to prepare for a professorship in sanitary engineering at that university’s school of public health. He was sent to the Massachusetts Institute of Technology (MIT) in Massachusetts, where he took courses beginning in the fall of 1928. He was quickly recognized as a “brilliant” student, and his fellowship was extended for an additional year. In the summers of 1929 and 1930 he was given the opportunity to observe a variety of public health programs in the United States, including a month each at Rockefeller-funded malaria-control stations in Alabama, Mississippi and Tennessee. Then in July 1930 (possibly because de Jesus was Spanish-speaking) he concluded his fellowship with a two-month internship with the Foundation’s malaria-control project in Puerto Rico. The University of Philippines then funded a four-month tour of public health institutes and programs in Europe. When he returned to that university in February 1931 he took a position in the Department of Sanitary Engineering, Industrial Physiology and Chemistry in the Institute of Hygiene, a position he held for the next two decades.
Dr. Shi-Chu Hsu, who had a degree from Cheeloo University (Jinan), was offered a fellowship to attend the Johns Hopkins University School of Hygiene, and began courses there in October 1937. He was reported to have done “excellent” work in bacteriology and public health administration during four quarters of study, and was sent in June and July 1938 for month-long observations of public health departments in New York and Tennessee. He returned to China to take a position as the Director of Rural Health in Sichuan Province, but in 1941 was sent to the Rockefeller-supported malaria project on the Burma Road (see below for a description of that project). In 1943 he was given a four-month fellowship to investigate public health activities and malaria research in India and Ceylon. In 1949 he was described by a Rockefeller officer as “a good malariologist,” and the next year appears in the archival record as an officer of the Joint Commission on Rural Reconstruction in Taiwan, a role he continued to fill into the 1960s.
Fellows were expected to return to their native countries on completion of their fellowships, and apply their newly-acquired knowledge to situations there. Their initial progress, and later accomplishments and disappointments, were duly noted in Rockefeller records. Some of the fellows maintained long relationships with the Rockefeller Foundation as grantees or advisors, adding to the ever-expanding global network of public health officials that was essential to the Rockefeller strategy of disease control.
Rockefeller Public Health Features: Collaborate
Fellowships awarded to promising individuals in every locale where the Rockefeller organizations could gain a toehold were important elements in the larger strategy of collaborating with national or colonial governments. The process of collaboration began with a formal invitation from a government to join in a particular public health program, although invitations did not come out of the blue but usually were the product of Rockefeller officers’ prior visits to the area. Subsequent to the invitation the IHB and later the RF sent an officer to that nation or colony to survey the situation and prepare a formal report; the archives are full of these lengthy and well-documented observations.
Usually the next step was to draw up a plan for a multi-year project, with a budget that included government contributions. Often these were five-year plans that were based on full Rockefeller funding in the first year, followed by annual increases in government funding and tapering Rockefeller support. This set the stage for Rockefeller officials to depart, and for indigenous leaders to fully administer the program, by the end of the fifth year. The hope and expectation was that the program then and in the future would be fully supported by the government. In sum, the ideal result was a locally- or nationally-funded program that would be managed by those favored individuals who had received Rockefeller fellowships, and this ideal was frequently achieved at the end of a program, even if it was not sustained.
A key contribution to initiating such programs was the ability of the Rockefeller officers to adapt to, and interpret to Rockefeller headquarters, the particularities of the governmental, educational, and cultural situation as they found them. Some of the leaders of the Rockefeller philanthropies had missionary parents, and many had either lived outside of the United States or had liberal educations, and those leaders tended to hire as field officers men and women who, like them, had knowledge, interests and skills beyond the necessary medical, scientific and technical training. Some of the officers they sent into the field certainly demonstrated considerable linguistic and cultural adaptability, giving them access to government authorities beyond that afforded by the power of the Rockefeller name.
In any case, the job of the Rockefeller officers was to collaborate with the existing governments so that the public health programs they were instituting would be accepted as permanent elements of the government apparatus. Resistance was expected because innovation required change that threatened authority structures and challenged existing concepts of health and disease. This was understood in the Rockefeller organizations, but the frank assessments and personal ruminations about the difficulties anticipated, and later encountered, seldom altered the professional optimism and determination of the field officers. Moreover, the coercive methods that often accompanied comprehensive public health administration were seldom regarded by the Rockefeller officers as problematic.
In practice some Rockefeller programs were highly successful in altering the course of public health administration. In Sri Lanka, for example, the Rockefeller strategy of creating local health units fundamentally changed, and apparently improved, public health in the colonial era, and formed the basis for a continuing program after independence. In India, a far more complex situation, Rockefeller programs were not colony-wide and, although they were in some respects an improvement over British colonial health programs, they seemed to have a much greater effect on higher education than on local administration. Specifically in regard to malaria, the Taiwanese program of the 1950s and 1960s was clearly based on the Foundation’s pre-1950 anti-malaria programs in both mainland China and Taiwan.
Rockefeller Public Health Features: Estimate
At the completion of a collaborative Rockefeller program an estimation of its results as well as a calculation of the cost of maintaining it in perpetuity was required. Every field officer reported regularly to New York headquarters: public health reports that were submitted monthly, quarterly, annually or at longer intervals fill the Rockefeller archives. Included in these reports are statistics regarding test areas, such as population, incidence of disease (measured primarily by spleen distension in the case of malaria), treatment trials or environmental actions, program costs, and follow-up assessments of disease incidence.
Such information was analyzed at the New York office by a professional statistician, who attempted to verify the effectiveness of the program not only in terms of lessening the incidence of disease, but also in terms of its finances. One key to the Rockefeller approach, often ignored in the histories of public health, was the home office’s insistence on developing economically effective disease-control programs. In the first instance the Rockefeller philanthropies were concerned that their monies were well-spent; but in the longer run it was the philosophy of the leaders of the IHB and then the IHD that their demonstrations had to produce verifiable project costs in order to show local and national leaders that disease-control was both practical and affordable. Otherwise, in the view of the New York office, there was little chance of convincing governments to adopt the Rockefeller methodologies permanently.
This element of the Rockefeller approach was derived from the prominent view during the American Progressive era, that expert knowledge could produce more effective and efficient government. There is an apparent contradiction in having the administrators of the wealthiest philanthropy the world has ever known exhibit an obsession with demonstrating economy in the administrations of health programs. The Rockefeller officers, however, were fully aware that the abundant funds they had at their disposal could be effective on a global basis only if they were used carefully and strategically. Moreover, they held the Progressive mentality that the best government was the least expensive government. Establishing an effective public health regime on the basis of an economically viable per-person cost was clearly an essential element of the Rockefeller approach.
The preceding review of the Rockefeller public health strategy provides a means of understanding and parameters by which to measure Rockefeller anti-malaria programs in East Asia. The following case studies demonstrate the Rockefeller strategy in action and testify to the success this model achieved.
Case Study: The Philippines
Undoubtedly the most important area in East Asia for the Rockefeller philanthropies was the Philippines, the only U.S. colony in the region. The Philippines was perceived as a valuable gateway for American influence in East Asia, but in public health terms it posed a risk as a possible source of contagion for North America through the immigration of Filipinos as well as the movement of American military forces to and from the archipelago. The International Health Board sought to address this risk, and established a good relationship with the United States government, its Public Health Service, and the United States Army, that made it easy to create and establish programs in the Philippines.
The Filipino government was receptive to IHB initiatives, which began in 1922. The Rockefeller strategy of promoting education was immediately evident, as four fellows were appointed, and courses in public health nursing training were started. In the first year 99 nurses were graduated. As a result of this reception, the Philippines became a prime trial ground for Rockefeller work on malaria, as historian Warwick Anderson has observed.
The first IHB officers in the Philippines were sanitation engineers who established a laboratory in Los Ba?os in 1922, and carried out malaria and insect-vector surveys. By 1924 Paris green was utilized to control mosquito larvae, and drainage improvements to reduce mosquito habitat were tried. The colonial government of the Philippines provided substantial funding for the project beginning in 1927. Unfortunately, through the 1920s the records of infection levels that were kept were incomplete, and it was impossible to tell, then and now, how effective the Rockefeller malaria work was.
Things changed late in 1929 with the assignment of Paul Russell, a research specialist and administrator with the Foundation, to oversee the Rockefeller work in the Philippines. He first trained new field and laboratory staff, not committing resources to a new program until he had an improved staff in place. They studied several species of malaria-carrying mosquitoes and carried out tests of Paris green and the use of larvae-eating minnows. In 1932 he proposed studying malaria in the restricted environments of mental and leper asylums, but eventually utilized a penal colony for an anti-malaria demonstration program using both Paris green for larvae control, and a new drug, Atebrin, for malaria control in infected individuals. Russell regarded all of his work as “directed primarily toward the problem of reducing costs of malaria control,” rather than malaria control itself.
Rockefeller malaria work in the Philippines ceased at the end of 1934, but left a legacy of malaria control work continued by large agricultural estates (or haciendas), and by the Army. The project’s final report took some credit for reducing the malaria death rate in the Philippines to about 25% of what it had been when Rockefeller work commenced 12 years before.
Case Study: Japan
The Rockefeller Foundation took the opportunity presented by the great Tokyo earthquake of 1923 to begin discussions with the Japanese government regarding public health. Early in 1924 Rockefeller officer John Grant was authorized to begin a preliminary survey of the Japanese public health system, centering particularly on the manner in which public officials were educated, and on identifying a disease that could be the focus of a Rockefeller project.
But instead of a general health program, the International Health Board quickly seized on the idea of creating a public health institute in Tokyo. Grant’s report had found no lack of governmental ability in Japan, but rather “the lack of effective application of public health knowledge.” In a manner similar to other institutes founded in the metropolitan centers of major Euro-American states, the Tokyo institute was expected to train workers and administrators who would influence public health practice throughout the Japanese empire. Further to this, Rockefeller observers understood clearly that the Japanese medical profession was engaged in “the Japanese national scheme of extending their influence throughout China.”
In the view of the Rockefeller officers there was great need for an institute because Japan’s public health regime was inadequate. This inadequacy was “largely due to failure to use modern administration and to basing preventive measures too exclusively on bacteriology.” Training in administration and in applied aspects of public health (including laboratory work) were exactly what Rockefeller-funded institutes of public health were intended to do. Unfortunately negotiations regarding the institute were tedious and fraught with problems of a political nature, both academic (regarding the appointment of a head of the institute) and international (anger about the United States’ quota law of 1924 that effectively excluded Japanese from emigrating to the U.S.). Finally in 1930 the negotiations for the institute began to coalesce, and the institute was opened in 1938. As John Farley has related, deteriorating Japanese-American relationships had by that time made support of the institute something of an embarrassment for the Rockefeller Foundation.
Case Study: China
Although the Rockefeller philanthropies had had interests in public health in China since the late 1910s, yet as will be discussed below in this chapter, malaria did not become a focus until 1940 when the U.S. government’s involvement in providing aid to the Nationalist government (even before the United States entered World War II) raised the question of the disease’s role in the interior of China. It was understood that malaria was opportunistic, and that the movement of refugees from areas in which malaria was endemic into otherwise unaffected regions, and the general deterioration of health that came with war, would likely lead to increases in the incidence of malaria. The central Chinese government began anti-malaria work in 1932, but progress was limited in that politically-fragmented, war-torn nation.
A Rockefeller officer in Hong Kong in the summer of 1939 (drawn to an investigation of malaria by the unexpected availability of funds that had been withdrawn from Japan and Indonesia because of growing international tensions) wrote a letter to the Foundation’s New York office that recommended the initiation of a malaria studies program in south and central China where it was “a major health problem.” He noted that Red Cross reports from Chinese military hospitals in those regions suggested that as much as 30% of the cases were chronic malaria, and that “this disease rivals or exceeds the intestinal diseases as a cause of sickness and disability.” Similarly, 30% of Japanese sick and wounded soldiers returning to Japan from China reportedly “showed malaria parasites in their blood.” The letter summarized: “it is entirely possible that malaria will play a role in the duration and the outcome of the war in China.”
The Rockefeller Foundation forwarded this report to the United States Public Health Service, which in turn confirmed the severity of the situation. Describing a recent meeting of American and Chinese officials in Washington in a reply to the Foundation, the Surgeon General of the United States (the head of the Public Health Service) assessed the situation in practical terms:
Secretary [of Treasury Henry] Morganthau [has] received reports of the prevalence of malignant malaria along the China-Yunan Road, the epidemic being of such severity as to imperil further construction progress. The Treasury Department is interested because of the importance of this highway as the only avenue through which tung oil can be transported for shipment to the United States. Proceeds from the sale of tung oil constitute the chief means by which China is repaying the loan given by the Export-Import Bank.
The Surgeon General’s letter concluded by offering to collaborate with the Foundation on “technical supervisory assistance” to the Chinese government on malaria-control measures, but then stating that “if the [Rockefeller Foundation] finds it possible to handle the whole situation, we would have no wish to interfere.” The Public Health Service in fact assisted with the early phase of the project, but then withdrew.
The Chinese government responded rapidly to the Foundation’s show of interest. F.C. Yen of the National Health Administration wrote from Chongqing early in August 1939 to reiterate “the seriousness and urgency for the need of control and treatment of some half-million workmen now undertaking railway, highway and other constructions” in Yunnan province. (Specifically, this was the Burma Road, being built to bring critical supplies into China overland, because the Japanese had blocked all shipping through the China Sea.) He asked “in what way the Rockefeller Foundation will likely be interested in the project,” and concluded by noting that an “Anti-malaria Commission, jointly organized by the central and Yunnan Governments, has already started in with its five-year program of work.”
An exchange of letters with M.C. Balfour, the Rockefeller Foundation’s representative in Shanghai followed, in which Yen suggested that recent graduates and current students at the Peking Union Medical College could be recruited for the project. Balfour responded by assuring Yen that the Rockefeller Foundation had an interest in supporting the project, but would want the project to be organized and operated by the Chinese rather than by the Foundation. Late in September 1939 Balfour recommended the project to Wilbur A. Sawyer, head of the International Health Division, and subsequently a grant was made.
A project headquarters was established at Chefang on the Burma Road during its first year. In December 1939 two representatives of the United States Public Health Service arrived “to train a selected Chinese staff in malaria survey and control methods,” but left the site in the spring after the Rockefeller Foundation’s representative, W.C. Sweet, took over liaison work. The project itself was staffed by L.C. Feng of the Peking Union Medical College’s Department of Parasitology (who was described as “loaned to Malaria Studies”), two other Chinese researchers, and several Chinese support staff.
In the first months of the project it was found that the local malaria “consist[ed] mostly of P. falciparum infections,” and that “the only vector of importance at all is A. minimus.” It was noted that “within a short time of arrival in Chefang, Chinese drivers and troops are heavily infected” with malaria. Throughout 1940, however, no specific anti-malaria measures were carried out.
By 1942 the anti-malaria program had become a collaborating unit of the Parasitology Department of the Chinese National Institute of Health in Koloshan, and was headed by Dr. S.C. Hsu. (See above for a discussion of Dr. Hsu’s Rockefeller fellowships.) The focus of his work continued to be surveys of malaria incidence rather than control, but these studies were now focused on Sapingpa, a suburb of the Chinese capital, Chongqing. (The Japanese army’s advance along the Burma Road had required the program headquarters to move from Chefang to the Chongqing region in June 1942.) A new laboratory building had been completed, but was still not in use by September 1942. The critical nature of supplies for this work was evidenced by a careful accounting of the use of gasoline for the laboratory’s automobile.
The tone of a letter in the summer of 1943 from Dr. Joseph Needham, of the British Scientific Mission to China, suggests that the malaria studies project in China remained a scientific affair. Needham stated that there were “a considerable number of workers actively engaged” in trying to find an indigenous anti-malarial drug, and urged the Rockefeller Foundation to support such a project because such drugs were “most urgently needed.” He argued that such work “could be regarded as a permanent contribution on the part of the Foundation, since additional anti-malarials would be useful after the war just as much as during it.” But the official Foundation response was to doubt “that the [anti-malaria drug] work in China … will produce results of advantage to the United Nations in this war. In reference to the urgent need for an effective quinine substitute, there is of course, atebrin or mepacrine.” Because these drugs were now being produced “on a tonnage basis…approximately equivalent to the pre-war world production and consumption of quinine,” the problem was “one of allocation and distribution.” Taking its classic stance, the response stated that the Foundation did “not wish to become involved in this general field,” in keeping with its overarching view that malaria would most effectively be controlled in the long run by environmental and anti-larval approaches, rather than by administrations of anti-malarials.
The program of studying malaria continued through 1943, with the addition of trials of Paris green for mosquito larva control. In the trial district “there was an appreciable improvement in the malaria indices compared with the adjoining…region.”
Plans for 1944 and 1945 included carrying out additional larva-control operations, and “a malaria course…including lectures, lab[oratory] work and practical field experience [for] a group of health officers.” Fifteen health officers were in fact trained in the fall of 1944. The possibility of merging the Rockefeller-funded program with the Chinese government’s National Institute of Health or National Health Administration was under consideration; indeed, the project had been effectively a Chinese one, because except for brief visits by Foundation staff in 1942 and 1943, no Rockefeller officer had been on site between 1941 and 1945.
In 1945 the first apparent spin-off occurred when “a special malaria unit was organized, largely with personnel of our [i.e., the Rockefeller-funded] malaria laboratory or trained by them, to assist the Chinese Army Medical Administration.” Meanwhile, after the war ended the Malaria Laboratory itself was reconstituted in Nanjing, and in 1946 three Rockefeller officers were sent there to help plan new and expanded studies. They were reported to be “undertaking the work with confidence” although it was clear that “China is still unsettled and economic conditions make it difficult to plan very far in advance.” For the first time the Foundation’s report on the project mentions the possibility of “field testing with DDT.”
The final statement of Rockefeller work in China, late in 1947, referred to “the political unrest in China, and the lack of interior communications” that severely limited the project. The best that could be said for the planning for the next year was that “it is believed…that the program proposed for 1948 is capable of execution.” Although studies were carried out in the immediate area around Nanjing, including tests of dichlorodiphenyl-trichloroethane (DDT), it is clear that the Rockefeller officers had moved the focus of their efforts to Taiwan, an island which was under full control of the Chinese central government.
Case Study: Taiwan
Rockefeller work in Taiwan had to take account of the public health programs of the former Japanese colonial regime. Since its occupation in 1895, the island of Taiwan had been regarded by the Japanese government as a model colony, and “medicine was meant to be a tool both for civilizing the colonial subjects and for legitimizing the colonial regime.” Japanese medical workers sent to Taiwan had training in sanitation procedures, and carried their knowledge to “remote towns and villages.” Malaria control was one of the earliest successes of the colonial regime, contributing to “a visibly healthier environment in Taiwan during the colonial period.” Nonetheless, malaria as a disease apparently was not a major area of study for Japanese physicians: one sent to Taiwan in the 1930s later recalled that “coming to Taiwan made me realize how little I really knew about malaria.”
The Rockefeller estimate of the Japanese anti-malaria efforts during the colonial era was negative. According to the survey report of 1946:
The program was evidently aimed at the conservation of manpower with the least possible expense and work. It was an unsound program from a public health point of view since it aimed at suppression of malaria rather than at prevention of transmission through mosquito control. That it was effective from the standpoint of the Japanese Government is seen in the malaria rates which show no material change for a 30-year period ending in 1941. That it was unsound is demonstrated by the epidemics of malaria which followed the collapse of the program during the war…[Moreover,] there is little evidence of comprehensive studies of malaria by the Japanese…No systematic studies of the epidemiology of malaria in Taiwan, nor studies of anopheline ecology were made. Spleen surveys were almost never done.
The report concluded that “the epidemics of malaria which followed the collapse of the program” during World War II were clear evidence that the Japanese program was “unsound.” Whether or not that assessment was warranted, the Rockefeller Foundation officers who conducted the survey were enthusiastic about Taiwan as a test site, writing that “Taiwan offers a splendid opportunity for productive work on the binomics of malaria and on malaria control.” In fact, in the late 1940s and early 1950s Taiwan joined Sardinia, Trinidad and Tobago, and Sri Lanka as islands that the Rockefeller Foundation viewed as ideal laboratories for trials of DDT.
Ka-che Yip has described the Rockefeller Foundation’s anti-malaria program in Taiwan in the late 1940s. Establishing a central field station at Chaozhou, which soon became the Taiwan Malaria Research Institute, and two satellite field stations, the Foundation initiated a classic program of study and trials. Mosquito vectors were carefully collected and dissected, local residents were examined for evidence of infection, and environmental conditions were implicated. Next, new drugs (Paludrine and Hetrazan) were tested, DDT spraying was undertaken in selected villages, and controlled flushing of watercourses (to control mosquito breeding) was attempted. Interestingly, some “equipment salvaged from the Burma Road program” had traveled all the way to Taipei and was put to use at the Institute.
The collapse of the Nationalist government on the mainland led to the termination of Rockefeller Foundation activity in all of China, including Taiwan. But in Yip’s view “the Foundation had helped to lay the foundation of the antimalarial campaign in Taiwan, and facilitated the completion of the preparatory phase.” Malaria work in Taiwan in fact proceeded through the 1950s under the auspices of the Sino-American Joint Commission on Rural Reconstruction, the World Health Organization, U.S. International Co-operation Administration, Taiwan Malaria Research Institute, and the Nationalist government of Taiwan, depending “to a large extent on the enormous amount of data already gathered during the preparatory phase.” In 1965 WHO declared that Taiwan was malaria free.
Conclusion
The anti-malaria activities of the Rockefeller Foundation in East Asia from the 1920s until the 1940s were scientific, educational, experimental, site-specific, and part of the Foundation’s global effort to establish a new paradigm for controlling, or even eradicating the disease. In this effort the Foundation was successful, in that the strategy it developed—attacking the mosquito vector—became the basis for the World Health Organization’s program of the 1950s and 1960s. In that sense, everything that the Foundation did was preliminary to WHO’s DDT-based program, and the DDT-based programs of several nations, that broke the pattern of malaria transmission in many areas of the world. The techniques, personnel, and many of the institutions that underpinned those programs had been constructed by the Rockefeller strategy of demonstrate, educate, collaborate, and estimate that has been outlined above.
However, there have been views critical of the Rockefeller anti-malaria activities. One leading critique is socio-political. It takes the view that the Foundation’s public health work was carried out in collaboration with colonial regimes, or even native regimes that did not function in the best interests of the bulk of the population. As historian Soma Hewa put it “Rockefeller philanthropic medicine did not come to rescue the people of the colonies for altruistic reasons; it simply carried on the imperialist tradition.” Another historian, John Farley, summarized the critiques of a “hard-edged group of ideologically-driven historians” as portraying the Rockefeller public health activities, including the anti-malaria work, as “enchanc[ing] the health and working efficiency of [people throughout the world so that they would be]…more attractive for American cultural, economic, and political domination.”
The other leading concern about the Rockefeller anti-malaria work is directly related to its scientific-technical approach that focused narrowly on the problem of the disease, and not more broadly on health. From this perspective, attacking the malaria problem alone left untouched the broader, underlying issues of poverty, malnutrition, and inadequate access to medical care, and thus did little to improve the lives of those living with malaria. It may seem particularly egregious that Foundation officers could set up experimental projects that over several years significantly reduced malaria incidence in particular locales, only to abandon those programs if local governments did not take them over as planned.
In the end, however, it must be acknowledged that the Rockefeller philanthropies, their intrepid staff, and the thousands of workers throughout the world that they brought into the struggle against malaria, accomplished a great deal. Even their critics recognize that millions were spared malaria infection, and a global health infrastructure was put in place whose legacy is with us today.