Liu Shiyung. Disease, Colonialism, and the State: Malaria in Modern East Asian History. Hong Kong University Press, 2009.
In 1939, the Japanese colonial government in Taiwan circulated a film to promote the anti-malaria program. The film made the claim that during most of the colonial period in Taiwan (1895-1945), the government had advocated an integrated approach to malarial control. This involved prompt diagnosis, the administration of drugs, proper case management, improved health services, community-based support systems, the use of insecticide and bed-nets, proper environmental management geared towards vector control, as well as continuous research in developing effective anti-malarials. The film illustrated three themes of the Japanese anti-malaria campaign: modern malariology, treatment, and environmental improvements. Although the scenario in the film was always smooth and uplifting, the anti-malaria program was, in reality, full of controversies. The tension between advanced technology and simple sanitary measures, quinine prophylaxis and environmental control, as well as costly vector eradication and cheaper social mobilization, was never resolved. At the same time, there was a time lag between theoretical research in modern malariology and its practical application by the government, and the time taken to formulate and implement anti-malaria policies tested the efficacy of the colonial government. This chapter highlights these themes in a review of the history of Japanese malaria control efforts in colonial Taiwan. Through an examination of the colonial government’s responses to the problem of malaria, this chapter shows that the legacy of colonial medicine is essentially mixed and that the complex and sometimes contradictory nature of colonial medicine can only be understood by detailed contextual research.
Malaria and Knowledge in the Ivory Tower
Before modern malariology was introduced into Taiwan, two major hypotheses existed to explain the unknown fever: the notion of zhangqi (foul air) from traditional Chinese medicine and the theory of “miasma” which was brought to the island by early Western visitors, including the medical missionaries. One such missionary was the Canadian George MacKay, who went to Taiwan in 1872 and lived there for about twenty years. He noted that malarial fever was the most common and most malignant disease in northern Taiwan and insisted that it was caused by “poisonous vapor” from the Danshui River during the summer season. Japanese colonial authorities in 1895 were well aware of the threat to the colonizers’ health posed by the many diseases on the island; in fact, many Japanese succumbed to disease when they began the occupation of Taiwan.
The miasma theory also influenced the thinking of many Japanese concerned with public health before the widespread adoption of bacteriology as part of mainstream pathological studies. In the first government report on Taiwan’s sanitation in 1898, the Japanese scholar Tsuboi Jirō indicated that Taiwan’s environment and the local people’s lifestyle were conducive to the spread of such diseases as cholera, plague, and malaria. Although he mentioned Robert Koch’s work on bacteriology in the report, he suggested that malaria was mainly caused by the “humid, hot, and poisonous” air on the island.
Throughout the colonial period, malaria was classified as an endemic disease or fudobyō (literally illness caused by local characteristics) according to Japanese medical definitions. The disease was seen to be related to the nature of Taiwan’s environment and the “uncivilized” behavior of the indigenes—a theme which is explored more fully in Ku’s chapter in this book. This assertion guided the Japanese study of malaria in Taiwan for almost 50 years. The colonial government’s first reaction to modern malariology was to identify the patients rather than control the mosquitoes.
This does not mean that Japanese malariologists in the 1910s were not interested in learning more about the anopheles mosquito. For example, Kinoshita Kashichirō, a scientist-physician, was also a naturalist who believed that the understanding of human biology (and pathology) could be achieved only through an understanding of the biology of all living things. To identify and collect anopheles mosquitoes soon became fashionable in Japanese malariology. By 1933, malariologists Morishita Kaoru and Katagai Tatsuo had shown that 69.2% of Anopheles minimus and 20.8% of Anopheles sinensis fed on human blood. They suggested that Anopheles minimus was the major malarial vector in Taiwan, and Anopheles sinensis was the most prevalent species on the plains. In 1936, Morishita listed fourteen species of anopheles mosquitoes found in Taiwan. In 1943 other malariologists, Omori Nobuhiko and Noda Hiroshi, discovered Anopheles barbumbrosus on the eastern coast of the island. Of all anopheline species, only Anopheles minimus and Anopheles sinensis carry plasmodium, which causes malaria. It is interesting to note that the Japanese had been more concerned with the suppression of malaria, and even though they carried out entomological studies, they were “largely taxonomic rather than biological or epidemiological.”
As quinine was the most powerful medicine to treat malaria, Japanese physicians developed different formulas between 1926 and 1940. There were twelve of these quinine-based prescriptions, each with different compounds. Among these, the most common was a therapy used in Taiwan which was in fact distinguished from those adopted by the navy and army in Japan. After World War II, the Taiwan prescription was combined with other medicines, Plasmochin and Atebrin, to form a more complex treatment regimen known as the Morishita method.
Like modern malariologists in the West, Japanese experts in colonial Taiwan also searched for substitutes for imported quinine. Today the most promising known anti-malarial is a Chinese herb, qinghaosu which is derived from sweet wormwood (Artemesia annua). Japanese researchers in colonial Taiwan focused on the Chinese herbs changshan (Dichroa febrifuga) and chaihu (several kinds of Bupleurum), both of which yielded relatively good results when tested. However, by 1933 neither medicine could be sufficiently and effectively produced. Moreover, the original test results were questionable since the tests involved fewer than 20 patients for each herb and there were no further reports about follow-up clinical studies. It seemed that Japanese physicians did not pin their faith on herbal medicine and were also unaware of qinghaosu. Apparently, the search for a Chinese herbal replacement for quinine was more of an academic exercise than anything. In 1950, a Japanese pharmacopoeia only had a very short entry on changshan which described it as “a malaria antipyretic contains unknown alkaloid, and some say it has therapeutic effect 100 times more than quinine.” The Japanese did not really expect to find a replacement for quinine, especially when it could be imported.
Another interesting aspect of malariology in colonial Taiwan was malariotherapy. In the 1910s, a time before there were antibiotics to treat late-stage syphilis, a Viennese physician, Julius Wagner von Jauregg, came up with the idea of treating patients who had syphilitic paresis, or dementia paralytica, by inducing fever. In 1917, he turned to malaria inoculation which proved to be quite successful. The patient was inoculated with Plasmodium vivax, thereby inducing several cycles of high fever, and quinine was used as a cure. Malariotheraphy institutions for halting the progress of paresis were established in many parts of the world. Japanese physicians were aware of such treatments from their promotion by the League of Nations after the 1920s.
According to a report by Wada Toyotane, Director of Experimental Malariotherapy at Osaka Imperial University, 1,153 Japanese patients received malariotherapy in his university between 1928 and 1938. It had been assumed that the procedure, although uncomfortable, was as benign as the parasite itself. Yet, Wada pointed out that:
among patients suffering from general paralysis who undergo an attack of benign tertian malaria in the hope of curing their mental disease, the fatality attributable primarily to the malarial attack is between 10 and 12 per cent.
Similar malariotherapy had also been carried out in colonial Taiwan from 1924 to about 1930. However, unlike their colleagues in Japan, Japanese physicians in colonial Taiwan saw malariotherapy as a potential way to treat venereal diseases and parasitic problems. One study published in 1936 recommended malariotherapy for gonorrhea, claiming that more than 20 patients had done well after the treatment. Another study in 1938 claimed that malarial fever could be used to “burn out” several parasites. The authors of both studies revealed the same attitude towards the application of malariotherapy: if we cannot beat malaria, then we have to learn to live with it and use it for our own good.
With great confidence, Japanese malariologists not only tried to re-test all Western discoveries in Taiwan and Japan, but also aimed to advance their own knowledge and understanding of the disease. To colonial officials, success in actually implementing ideas developed in malariology laboratories might mean the elimination of malaria in colonial Taiwan. This optimistic attitude, however, faced crucial challenges.
Anti-malaria Policies in Practice
The colonial government in Taiwan invested in anti-malaria programs to improve the chance of survival of the colonizers, making treatment of the disease a “tool of empire.” Medical facilities and regular blood-screening systems were established in many Japanese settlements and enterprises. Anti-malaria technologies developed in the academy and laboratories were introduced into these sites, but they proved difficult to apply in practice.
As the Japanese identified malaria as an environmental problem of the tropical colony, one of the methods of controlling it was the introduction of sanitation measures, including drainage and avoidance of swampy areas in Japanese settlements, which were generally located in cities and military compounds. The second method was prophylaxis using various cinchona preparations, most commonly quinine, which was carried out sporadically in checking stations in the settlements. In 1906, a pilot program to test the diagnosis of malaria and use of quinine prophylaxis was initiated. The colonial government did not introduce an anti-malaria program earlier partly because of financial constraints; it often complained that the importation of quinine involved considerable outlay and restricted its uses. Moreover, to most colonial officials, malaria, while insidious, was chronic and the impact of plague and cholera was more severe, requiring immediate action. Malaria was almost an accepted way of life among the indigenous population and they did not respond actively to government anti-malaria programs despite abundant evidence that malaria was a major health problem.
Modern malariology was based on the theory of anopheles mosquitoes as vector and it was known that malaria could result from domestic as well as imported transmission. Anti-malaria efforts involved not only the improvement of local sanitation conditions to interrupt transmission, but also the imposition of quarantine when necessary. In 1910, Advisor of Sanitation Takagi Tomoe proposed a broad policy of malaria control to the new Governor Sakuma Saumaō. Takagi’s plan centered on quinine prophylaxis and limited efforts in mosquito eradication. The key feature was the establishment of anti-malaria stations which would carry out blood tests in the Taiwanese community and apply quinine prophylaxis, mainly to Japanese residents. The number of stations increased from 12 in 1911 to 185 in 1942, with the total population examined expanding from 1,600 in 1910 to 6,276,695 in 1942.
While medical practitioners were mainly interested in the practical application of quinine prophylaxis, others worried that quinine was not taken by enough people for malaria transmission to be interrupted. Such concerns affected the development of anti-malaria policy in subsequent decades. In 1913, the government modified the policy to integrate quinine prophylaxis with broader sanitation improvements. In addition, an important part of the policy was the education of the public in malaria prevention.
The new policy therefore was a combination of quinine prophylaxis (still conditioned by financial constraints), education, and sanitation reforms. Generally speaking, the application of quinine prophylaxis was meant to improve the chances of survival of Japanese settlers, and the introduction and enforcement of sanitation measures and health education aimed to improve the environment and living conditions as a whole. Both were features of Japanese anti-malaria policy until 1945.
In the 1920s, with the priority given to the anti-vector approach and an increased emphasis on environmental control, the supply and use of quinine remained roughly the same. This meant that the colonized had to shoulder the burden of anti-malaria costs through the purchase of bed-nets, mosquito coils, and other preventive devices. Urban sanitation improvements, however, would be supported by taxation if urbanization and economic growth continued. Certainly, the fact that most Japanese lived in cities provided the justification for government investments to improve the urban environment in the colony.
The limitations of the sanitation measures and quinine usage became evident when the government applied the strategy to a broader and much less developed area. During the 1920s, Japanese migrants exploiting new lands in eastern Taiwan suffered greatly from malaria. There were neither proper sanitation plans for new settlements nor the prerequisite medical supplies to treat major diseases, especially malaria. As noted, the colonial government had adopted quinine prophylaxis on an experimental basis in 1906, but the experiment had been implemented sporadically only among Japanese in the immigration villages, government plantations, and major industries owing to financial constraints. Evidence shows that Japanese medical professionals tended to pin their faith on quinine prophylaxis, and hoped that quinine would protect Japanese settlers from being infected by settlement outsiders such as the Taiwanese and aborigines. Owing to epidemics and various natural disasters as well as financial difficulties, the eastward migration program finally came to an end in the 1930s. Many settlers returned to Japan or relocated to the cities in western Taiwan. Even though the names of the settlements remained, Japanese settlers had fled and the villages had been demolished.
The failure of the colonial government in keeping Japanese settlements malaria-free revealed the difficulties in the application and practice of Japanese malariology on the island as a whole. Government statistics did, however, continuously show a downward trend in the malaria mortality rate. Malaria mortality dropped sharply after 1924, and that it remained low throughout the 1930s without any serious reversal in the decline. A study also confirmed that malaria was no longer a major factor in the crude death rate (CDR, the average number of deaths per 1,000 people), especially after the 1930s.
But advances in Japanese malariology could not protect all Japanese settlements and a comparison of the number of malaria cases in western and eastern Taiwan reveals regional differences in morbidity rates and the importance of the spatial factor in morbidity patterns. The malaria morbidity rate in western Taiwan declined after 1920. This may be attributed to improved sanitation in many western cities after that date. On the other hand, although areas in the east enjoyed a similar trend of decline from 1920, the rate increased again after 1923 and this higher rate was maintained between 1927 and 1940. The reduction of Japanese settlements in eastern Taiwan discussed above shows the limitations of the preventive strategy that relied solely on current malariology as practiced by the Japanese. Western Taiwan obviously had conditions for applying similar strategies that yielded better results.
Urban versus Rural
Like most public health reforms, the anti-malaria campaign in colonial Taiwan began in the cities rather than in the countryside. Better economic conditions and social organization might explain its relative success in the cities. Because of urban development, every city had several public and private medical facilities after the 1920s. They not only provided necessary medical aid, but also helped educate the public in malaria prevention. The doctor to population ratio of 0.62 (physicians per 1,000 people) in the three major cities—Taibei, Taizhong, and Gaoxiong—was much better than the average ratio of 0.39 in Taiwan as a whole. In addition, urban residents in western Taiwan enjoyed relatively easy access to different kinds of medical support. Increasing numbers of pharmacies and drugstores not only sold mosquito coils and spray, but also medication to ease suffering. Mosquito coils and spray were not very expensive, and although the sale of the only effective medicine, quinine, was monopolized, many over-the-counter medicines and common prescriptions were available to help vivax patients endure the cycles of pain, and increase the chances of survival. Medicines like senega, antipyrine, and aspirin were commonly used in hospitals and clinics, the last two were in fact available without prescription.
In addition to the traditional hokô system and sanitation police force, modern means of communication were available to support anti-malaria activities in the cities. The newspaper was a powerful tool to educate the public about, and alert them to, the medical problem. For instance, Taiwan NichinichiShinpō (Taiwan Daily News) announced news of the showing of anti-malaria movies, and included discussions of the disease in northern Taiwan. Exhibition was another channel to promote the anti-malaria message, and “Malaria and its Prevention” was one of the main features in the exposition “The First 40 Years of Governance” in 1935. One writer claimed that one-third of the island’s population visited the exhibition. The most influential network in the cities, and later in the countryside, was the public schools. As noted previously, the Morishia method of blood sampling was introduced in 1936 and was soon administered to school students. Meanwhile, diagnosis based on splenomegaly—which proved to be very useful in identifying malaria infection—was also introduced in every school and in localities without prevention stations. All suspected cases had to be reported to local hospitals and their families had to have follow-up examinations for three to five years.
An urban environment and lifestyle could also reduce the risk of infection. Miyahara Hatsuo once critiqued Morishita’s “environmental cleanness” concept, claiming that the reduction of the malaria infection rate in the cities was actually not “the result of environmental cleanness, but the result of polluted sewage system that Anopheles sinensis larvae cannot survive in.” Anopheles minimus and Anopheles sinensis were the two species that transmitted malaria in colonial Taiwan, the former found mostly in the mountainous areas in the east, while the latter mostly on the plains in the west. These species have very different habitats; Anopheles sinensis commonly breed in paddies and especially need clean fresh water, while Anopheles minimus prefer the highland environment. A study in 1954 seemed to confirm Miyahara’s 1939 observation. It showed that “the population of Anopheles sinensis was dramatically reduced in the West (Taiwan) and was even absent in the cities.”
The Wushantou Dam and Malaria Control in the Countryside
The countryside in western Taiwan remained in the grip of malaria even when urbanization and better living standards in the cities had contributed to the decline in malaria transmission. The colonial government, however, decided to develop anti-malaria programs for the countryside because of economic concerns, and the deciding factor was the construction of the Great Jia’nan Irrigation System and Wushantou Dam in the 1930s. To build the irrigation system and dam, the colonial government moved the anti-malaria battlefront to the countryside in the west, and at the same time attempted to improve the working conditions at the construction sites. Because of the project, more than 60% of the plains in western Taiwan were covered by a comprehensive anti-malaria program. The program not only transferred important elements from the urban experience, but also reinforced preventive measures by building better infrastructure. The moderate decline of malaria mortality between 1920 and 1930 revealed the achievement in urban areas, and the accelerated drop in the rate after that might well have resulted from the anti-malaria program in the countryside promoted during the construction of the Wushantou Dam.
Knowledge of modern malariology was applied fully when the colonial government began the construction of the irrigation system and dam in 1929. In that year, an estimated 200,000 cases of malaria with 4,025 deaths annually occurred in Taiwan, mostly in the south, e.g., in Jaiyi, Tainan, and Gaoxiong. In fact, it was anticipated that dam construction would further increase malaria infection once the project got underway. Water reservoirs had been constructed elsewhere on the Jia’nan Plain between 1920 and 1928, and in almost every instance, more mosquitoes and increased malaria infection had resulted.
The construction managers were aware of the danger, and even before the first working tunnel was built across the river, an expert team of malariogists, entomologists, biologists, and engineers was hired as a permanent unit to devise ways to control mosquitoes and malaria. Before 1930, the Dam Administration tried to control mosquito breeding by pouring kerosene and/or Paris green (a powdered arsenic-based formulation) on water surfaces without much success. Also, the Koch method of quinine prophylaxis was used mainly with the Japanese contractors and crew. The entomologists soon discovered that female mosquitoes laid eggs only at the margin of the lakes and the larvae congregated around the aquatic foliage in the shallow water. The entomologists, malariologists and engineers, working together, found out that by strategically raising and then lowering the water levels, which could be done at will, the Anopheles minimus and Anopheles sinenisis larvae could be killed when deprived of water. Drainage of the wetland swamp also reduced the number of mosquitoes. These preventive efforts claimed nearly 30% of construction costs between 1929 and 1931. Malaria infection did not increase as had been feared and actually slowly declined. As late as 1933, there were still about 3,021 cases of malaria annually although better management and improved health services had reduced the mortality rate to about 200 people each year.
Malaria control during the construction relied mainly on anti-vector measures and quinine prophylaxis. An increasing number of anti-malaria stations were set up after 1926, specifically in the rural Jia’nan region, and these stations appointed public health officials responsible for teaching villagers to clear bamboo bushes and water receptacles, and, if possible, install screens to protect the sick. In some instances, officials would spread larva-killing oil on larger breeding sites and send squads to destroy containers that might hold rainwater. Although screens could be quite expensive and were only commonly used in military compounds or commercial districts, the total effect of the efforts contributed to a slow but steady improvement. The establishment of anti-malaria stations in the countryside reinforced the network that already existed to promote the anti-malaria effort: the hokō system, public dispensaries, sanitary police, and the growing number of elementary schools after the 1920s. These stations played a role similar to that of public hospitals in the cities, helping to transfer malariology from the laboratory as well as the urban experience to rural Taiwan.
Advances in Malariology and Claims of Success
The importance of malaria studies in the anti-malaria effort was demonstrated again after the Great Hsinchu (Xinzhu) Earthquake in 1936. The earthquake was followed by outbreaks of epidemics, including malaria, which proved to be quite severe. Morishita’s investigation of the distribution of malaria cases indicated that they were related to the existence or absence of anti-malaria stations in various locations after 1906. He immediately urged the government to rebuild old, as well as construct new, stations. The success in building anti-malaria stations and introducing splenomegaly examinations at each elementary school provided more cases for scientific study as well as the development of new therapies. Indeed, researchers were able to collect necessary and sufficient samples through coercive blood examinations in the anti-malaria stations.
Malariology made significant advances in the 1930s. Three species of human malaria (Plasmodium falciparum, P. malariae, P. vivax) and one of monkey malaria (P. inui) were confirmed to be indigenous. The diagnosis and examination of Plasmodium were improved. As noted, Morishita introduced a new blood screening method in 1936 which increased the accuracy rate to 80%. Scientists in colonial Taiwan also developed their own unique quinine treatment regimen or the “Taiwan adjustment” after the 1930s.
Japanese malariologists in the 1930s were quite confident of their work and tended to exaggerate their accomplishments. According to a 1935 study of mosquitoes and anti-malaria measures on the Jia’nan plain where the irrigation system was located, the distribution of mosquitoes on the Jia’nan plain and in several mountainous areas was roughly the same as noted in official records before the establishment of anti-malaria stations, although the respective density of the minority Anopheles minimus and the majority Anopheles sinensis was significantly lower. As for the use of quinine prescriptions, the so-called Taiwan adjustment was quite similar to the treatment approach advocated by the World Health Organization in the 1950s. Yet, studies in the postwar period also concluded that the prescription developed in Taiwan was useful in curing the patient, but had no effect in suppressing relapsing cases. Thus, malariologists in colonial Taiwan might have overstated their case when they claimed that the Taiwan adjustment would “cure malaria patients and was an effective agent for malaria relapsing.”
Finally, despite the decline in the mortality rate of malaria after 1924, the number of Plasmodium carriers actually increased after 1931, as Figure 3 shows. Japanese malariogists and contemporary researchers attributed the increase to the improvement in test accuracy by using Morishita’s method of blood examination. Yet if we consider the declining number of cases of malaria patients in hospital reports, the increase might also mean that more people were becoming healthy carriers after long-term intake of quinine, especially since more medical supplies were now also available in the countryside. A study in 1954 had concluded that the overuse of quinine would produce quinine-resistant malaria, and the patient would remain sick but not die. If that were the case, the anti-malaria campaign could suppress the disease on the plains, but increasing numbers of carriers might spread the disease to remote highlands where the anti-malaria program was not widely implemented. The outbreak of malaria in the early 1950s could have been caused by evacuees relocating to more remote areas. A similar situation occurred in various European countries from the late 1940s to early 1950s.
The Japanese anti-malaria strategies developed by modern malariogists after the expansion of the program in the 1920s and 1930s gained the support of some Taiwanese. As A-nan, a 72 year-old male reminisced:
in school,…we had routine blood tests and physical examination every semester,…at home, the sanitation policeman was rigid in environmental cleanliness and clearing….From newspapers, I gained a lot of knowledge about malaria and…when I was infected, I believed the doctor would give me proper medicine.
It appears that after academic malariology was put into practice in the 1920s, the colonial government was able to use institutional and medical channels to educate the colonized society, and popularize facets of this scientific subject among a generation of Taiwanese like A-nan who was a school boy in the mid-1930s.
Concluding Remarks
The study of modern medicine in a colonial context can be situated at the crossroads of the histories of medicine and colonialism. However, as the medical historian Warwick Anderson has pointed out, postcolonial approaches have yet to be applied on a systematic basis to the field of colonial medicine, and the study of colonial medicine is still in its infancy. While scholars have certainly underscored the practice of colonialism, the construction of colonial cultures, and the discourses of the colonial politics, few have attempted to examine how colonial medicine was articulated in the first place. That is, the discussion of colonialism may neglect the power of technological development, and the study of technology could miss the socio-economic framework. This chapter examines the development of malariology and anti-malaria policies within a colonial socio-economic context. Taking as a starting point Edward Said’s contention that colonialism is first and foremost a struggle over geography, this chapter studies the Japanese colonial anti-malaria campaign, especially the spatial aspect that has been neglected, and uses specific cases to gain a better understanding of the importance of local factors in the practice of modern malariology in colonial Taiwan.
Malaria in colonial Taiwan ranked among the major health problems. It restrained colonizing activities in the cities and the countryside, and combating the disease required significant financial and organizational resources. As this chapter has shown, the development of the anti-malaria program, came together with economic needs, social realities, and the over-confidence of colonial experts on malariology in the ivory tower to render the anti-malaria campaign in colonial medicine extremely complex.
The story of the anti-malaria campaign in colonial Taiwan can be looked at from three levels: theory, availability, and practice. The theory and research of malariology done in the laboratory provided confidence to the malarial experts and the colonial government. With confidence in modern malariology, colonial officials adopted available methods for preventive and curative needs in the cities and Japanese settlements. Yet the failure of Japanese migration settlements and the limited success of the urban-based anti-malaria campaign in the 1920s meant that the preventive program could not depend solely on medical technology; it had to include measures to deal with the socio-economic conditions of the population, and it would be impossible to exclude the needs and specific local requirements of the rural indigenous communities in policy formulation and implementation. The extension of the anti-malaria program during and after the construction of the Jia’nan Irrigation System validated the fact that advanced technology was no guarantee for success, and that public health policies such as the anti-malaria program could not succeed without taking into consideration non-medical factors. Such arguments may be cliché to many Western scholars, but they have not yet been widely discussed by scholars of colonial and post-colonial Taiwan.
The key note of Japanese anti-malaria propaganda, that better theory would make more methods available in practice and would guarantee a healthier environment, was reflected in the background music of the 1939 film mentioned at the beginning of this chapter. The producer used a maestoso symphony for the section about modern malariology, light jazz to accompany promising treatments, and finally, an Arcadian eclogue for the improvement of the rural environment. There is no mistaking, however, that the main message the movie (and indeed the program itself) left with the Taiwanese was “confidence in modern medicine,” with the subtext of “integration with the local context.”