Perceptions and practices of public health in Guangzhou before 1932

After the 1911 Revolution, Guangzhou, as elsewhere in China, witnessed the emergence of a public health infrastructure in which the government and Western medicine played an increasingly dominant role. The local government perceived the public health domain as an expression of its political authority and Western medicine as an expression of modernity. However, public health is a universal concept with a local expression. There are always gaps between perceptions and practices caused by factors such as resources available, local power structures, and the different agendas of the various parties involved. As a result, Republican Chinese cities were by and large striving towards common goals but fell short of achieving them in similar or totally different ways. Although a comparison between Guangzhou and other cities is beyond the scope of this paper, the processes Guangzhou went through may still epitomize China's efforts and challenges in its search for modernity in medicine and health. In this paper I will outline the development of the public health framework in Guangzhou from the 1911 Revolution to the eve of the 1932 cholera outbreak. This period can be characterized by the prevailing importance of traditional charitable halls in the provision of medical services to the general public and the expansion of a governmental public health system that embraced Western medicine and whose work was constantly hampered by a lack of funding, and the increasing hostility of modern physicians toward traditional physicians. These trends would affect the way in which the 1932 cholera outbreak was managed in Guangzhou.

In Guangzhou, the conviction that the government had to shoulder most of the responsibility for providing medical care to improve public health did not come into being until after the 1911 Revolution. There were government-funded medical institutions in Imperial Guangzhou such as the hospital for lepers (mafeng yuan) located on the eastern side of the city. However, this hospital did not provide medical treatment, and the primary purpose for its establishment had been to separate lepers from healthy people for fear of contagion.Footnote ⁵ During the bubonic plague that struck Guangzhou in 1894 and subsequently killed 100,000 people in the city, John Kerr, an American medical missionary working in Guangzhou, complained that in ‘the great city of Canton. . . there was no Sanitary Board, the government adopted no sanitary or preventive measures, there was no isolation of cases, no removal of filth or rubbish, no water supply, no system of drainage, and. . . Chinese medicine and Chinese superstitions had full and unrestricted sway’.Footnote ⁶ The plague did not accelerate the development of the Guangzhou government's sanitary infrastructure. On the contrary, many charitable organizations set up by local mercantile elites before or after the outbreak of plague began to assume a prominent role in providing medical and social services for city-dwellers. These ‘extra-bureaucratic’ organizations, to use Mary Rankin's term, provided medicine and burial services for free or at an affordable price.Footnote ⁷ Collectively known as the ‘nine charitable halls (jiushantang)’, these organizations set up by local elites took advantage of the political instability during and after the 1911 Revolution to extend their influence from the social to the political realm. In the Republican period, the relationship between the charitable halls and the Guangzhou government, as we will see below, was both precarious and ambiguous. On the one hand, the political authorities relied on the charitable halls to cater for ordinary people's welfare needs. One the other hand, the charitable halls were occasionally subject to the government's financial extortion and criticisms of how they handled medical and welfare issues.Footnote ⁸

The 1911 Revolution brought about a new regime which began to perceive that one of the obligations of a modern government was to provide a public health infrastructure and an effective means of epidemic control. In 1912, the Department of Public Health was set up and the first-ever commissioner of health of Guangdong province assumed office, with duties covering the registration of medical practitioners, vaccination of smallpox, reporting of infectious diseases, handling of dead rats, registration of deaths, and so on. In 1920, after almost a decade of political turmoil that followed the 1911 Revolution, a municipal government was set up in Guangzhou and Sun Ke (1891–1973), son of Sun Yat-sen, was appointed mayor. Educated in the United States, Sun Ke, not surprisingly, organized the municipal government along Western lines, setting up six bureaus—education, public health, public security, public works, public utility, and finance—headed by Western-trained specialists. Sun Ke held a strong belief that sanitation (weisheng) should be an important element of urban planning and that the city should be a healthy place for people to live. He appointed Hu Xuanming, who received his public health education at Johns Hopkins University in the United States, to head the Public Health Bureau.Footnote ⁹ However, the Bureau was hampered by a shortage of government revenue and constant changes in personnel. Hu stayed in office for only three months, and within the 12-year period from the Bureau's establishment to the cholera outbreak in 1932, the head of the Bureau changed 14 times.Footnote ¹⁰ Its administrative structure was also revamped for financial reasons.Footnote ¹¹

Management of human waste was the major concern of the newly founded Public Health Bureau. The reason for this was not only that proper disposal of human waste was an important component of public health, but that human faeces generated considerable profits. Human waste from households and public toilets in Guangzhou were originally collected by ‘night-soil merchants’ (fenshang) of the night-soil trade associations who would then sell it to farmers as fertilizer. In 1930, driven by its intent to monopolize the profits of this lucrative trade, the Public Health Bureau contracted out the collection of night soil to a company. Facing strong resistance from the night-soil trade associations, the government explained that the policy was adopted in the interest of public health. First, the night-soil company would be subject to stringent sanitary regulations in terms of when the night soil was collected and how it was transported to designated spots. Second, the company would be entrusted with the task of improving the public toilets in the city. However, the company failed to deliver on any of its promises and complaints about the poor condition of toilets abounded.Footnote ¹²

However, the control of infectious diseases, which was another important concept in public health, made very little progress before the 1932 cholera outbreak. Dr Li Shufen (1886–1966), the first commissioner of health and a graduate of Edinburgh University, proposed that an isolation hospital be built soon after he assumed office in 1912. His suggestion was not heeded until Guangzhou was struck by smallpox in 1913, prompting the government to convert a temple into an isolation hospital to accommodate the smallpox patients. However, the military appropriated the isolation hospital in 1920 and turned it into a sanatorium for its officers. In 1921, the municipal government converted another temple in the northern suburbs into a hospital for infectious diseases. Nonetheless, the Public Health Bureau never stopped bemoaning the poor conditions of this hospital, pointing out that it was dilapidated and too small.Footnote ¹³

Sanitation and public health could go nowhere without hospitals and Western-trained medical practitioners. Although there were hospitals and medical training schools in Guangzhou, they were principally in Western or private hands. In fact, Western missionaries had undertaken to advance Western medicine and train modern medical practitioners in Guangzhou since the nineteenth century. For example, Peter Parker (1804–1888) opened the Canton Hospital in 1835 and founded the China Medical Missionary Society in China in 1838, and Mary Hannah Fulton (1854–1927) of the Presbyterian Church founded the Hackett Medical College for Women in 1905. The French Ministry of Foreign Affairs also founded the French School of Medicine of Canton in 1908 at the request of the governor general of Guangdong and Guangxi provinces.Footnote ¹⁴ These medical schools and their graduates paved the way for the expansion of Western medicine in Guangzhou well before the formation of the Public Health Bureau in 1920.Footnote ¹⁵ However, with the gradual consolidation of the government medical system, these Western (and thus imperialist) medical institutions were relegated to a secondary role.Footnote ¹⁶

As Iris Borowy has pointed out, ‘medicine and health [was] a means of safeguarding political sovereignty’.Footnote ¹⁷ To assert its own medical authority, the Guangzhou municipal government opened a public hospital in 1921 in the northwest of the city.Footnote ¹⁸ Efforts were also made to train modern medical practitioners at the government-run Guangdong University, which was built in 1924 and was renamed Sun Yat-sen University in 1926. As noted by J. A. Jewell, Japan and Germany were the two most popular countries for Chinese students to study medicine, followed by the United States, Britain, and France. As a result, modern physicians in Republican China were divided into two schools: the ‘German-Japanese school’ and the ‘Anglo-American school’.Footnote ¹⁹ Given the influence of German medicine, it is no surprise that the Sun Yat-sen University's medical school offered a five-year curriculum modelled on that of Germany. German medical practitioners were hired as professors and students had to learn German in their first year of study. Approximately 30 students were admitted per year. Apart from training modern medical practitioners, the medical school also provided medical services to the poor for free. In 1925, Sun Yat-sen University appropriated two existing hospitals and put them under the control of its medical school, naming them No. 1 Affiliated Hospital and No. 2 Affiliated Hospital.Footnote ²⁰

The expansion of public health and modern medicine eventually threatened traditional medical practices. Dominated by practitioners of Western medicine, the Public Health Bureau started to promulgate sanitary legislation to eliminate medical practices it considered unscientific or superstitious. In 1929, the Guangzhou government issued a decree forbidding temple attendants from prescribing in the name of deities (known as shenfang or xianfang) for worshippers.Footnote ²¹ Confrontations between Western medical practitioners and traditional doctors occurred at the national level in 1929 and in Guangzhou in 1930. In February 1929, a public health conference convened by the Ministry of Health in Nanjing passed a resolution entitled ‘The abolition of old medicine in order to clear away obstacles to medicine and public health’, which required traditional doctors to register with the government and take training courses to continue their practice. Chinese medical practitioners from 17 provinces formed a national association and successfully pressed the conference into rescinding the resolution.Footnote ²² In Guangzhou, the head of the Social Affairs Bureau, Wu Boliang, himself a Western-trained doctor, undertook to limit the use of Chinese medicine by imposing restrictions on charitable halls. In 1930, Wu proposed that all charitable halls in Guangzhou that provided medical services be required to abandon Chinese medicine and use Western medicine instead. The proposal was met with strong opposition from Chinese medical practitioners in Guangzhou, and when Wu relinquished office in 1931, his controversial mission remained unaccomplished.Footnote ²³

In sum, modern medicine and a government public health system began to take shape and expand in the early Republican period. The municipal government established the Public Health Bureau, set up a public hospital and a medical school to train modern medical practitioners, and set out regulations governing the management of human waste and the use of traditional medical practices. Dr Wu Liande (Wu Lien-teh, 1879–1960), a prominent figure in epidemic prevention in the late Qing and Republican periods, made a positive comment about the public health reforms in Guangzhou in his study published in 1932, noting that ‘public health work at Canton was placed upon a firm basis when a municipality was established in 1920’.Footnote ²⁴ However, this assessment should be treated cautiously, as the public health infrastructure alone does not tell the full story. The government budget allocation to public health institutions and how the government managed public health crises needs to be examined in order to make a more informed judgement. In 1932, more than 50 per cent of the Guangzhou municipal government's total public welfare expenditure was spent on road maintenance, and 20 per cent went to poor relief works (such as providing shelters for the needy). Only 9.2 per cent was spent on public hospitals, and 8 per cent went towards maintenance of the sewage system.Footnote ²⁵

The development of public health in early Republican Guangzhou can be assessed on both the discursive and institutional levels. Public health was no doubt a powerful discourse. The Public Health Bureau and modern physicians were able to draw on the discursive power of public health to wipe out traditional organizations, which were perceived as obstacles to their assertion of authority and the acquisition of profits. In the name of public health, the Public Health Bureau disbanded the night-soil trade associations and seized the profits from the sale of human faeces. The head of the Social Affairs Bureau, himself a modern physician, tried to make illegal the use of traditional medicine in charitable halls (though his work was left unfinished when he stepped down). However, the Public Health Bureau as a government institution was weak, as it was crippled by staff turnover and a shortage of funding. Public health did not rank highly on the government's public welfare agenda. The isolation hospital, the importance of which can only be understood in times of epidemics, did not receive much attention. The frequent replacement of the head of the Public Health Bureau can be interpreted as both a consequence and a cause of its weaknesses. The cholera outbreak of 1932 would fully expose the inadequacy of this public health framework, including its lack of resources and the lack of power modern medical professionals wielded in the government bureaucratic structure. At the same time, however, it would provide an opportunity for these modern physicians to assert their authority, including an escalation of assaults on Chinese medical physicians that had started in 1929.

The cholera epidemic of 1932: explaining the disease

Though various countries across the world were ravaged by cholera in the 1830s, the bacteria that caused it—known as cholera vibrio—was only identified in 1884 by Robert Koch (1843–1910), a German physician.Footnote ²⁶ It is commonly accepted that cholera originated in India and that there were six serious cholera outbreaks around the world in the nineteenth and twentieth centuries. However, there is a debate as to whether it existed in China before the nineteenth century. Some scholars argue that because huoluan (the Chinese term for cholera) is found in ancient Chinese texts, cholera dates back to ancient times in China. However, critics of this view argue that the huoluan referred to in Chinese texts before the 1830s and the form of cholera that occurred in China in the nineteenth and twentieth centuries are in fact two different diseases. They contend that because huoluan in the past generally referred to gastro-intestinal infections, colic, appendicitis, or ptomaine poisoning, it should be distinguished from the ‘true Asiatic cholera’ of recent times. It is generally accepted today that the true strain of cholera first showed its virulence and epidemic characteristic in China in 1820. The next serious outbreak occurred in 1837. Although the victims of these two cholera outbreaks displayed symptoms similar to those of huoluan patients in the past, some contemporary Chinese medical practitioners pointed out differences in the nature of the two strains, offered new treatments, and adopted the name diaojiaosha (literally ‘contracting the tendons of the legs’ disease) to distinguish the new form of cholera from huoluan. In the cholera outbreak of 1862, it was estimated that one-eighth of the population in the region of Shanghai and Songjiang died from the disease. Yet little is known about the responses of the government and the general populace to the cholera outbreaks in nineteenth-century Guangzhou.Footnote ²⁷

Guangzhou was again struck by cholera in 1913 and 1921. The Public Health Bureau responded in July 1921 by issuing ten regulations that instructed people how to prevent infection. The first stated that cholera was caused by unclean food, and that contaminated food, particularly cut fruit such as watermelons, should be avoided. The regulations also instructed people to drink boiled water and thoroughly cook vegetables. As the disease was highly contagious, patients should be isolated. In addition, the Public Health Bureau proposed the temporary closure of the bathing pool on the waterfront of the Pearl River, explaining that the river water might have been contaminated.Footnote ²⁸ The message these policies conveyed to the populace was that food hygiene was of the utmost importance in the prevention of cholera, although the instruction that people should drink boiled water and the closure of the bathing pool clearly indicate the government's awareness of cholera as a waterborne disease. Was the ‘cholera discourse’ in 1921 that put the emphasis on food hygiene rather than water hygiene a deliberate act? We will come back to this question in the final section of this paper. In any case, the 1913 and 1921 cholera outbreaks were mild in comparison with the 1932 outbreak, and thus did not bring about conceptual and structural changes in public health as the 1932 epidemic would do.

The cholera outbreak that swept across China in the summer of 1932 ravaged many major cities, including Shanghai, Guangzhou, Nanjing, and Tianjin. A sanitary report conducted by the Hong Kong government and released in 1933 estimated that there were over 100,000 cases in China, with a death rate of 50 per cent.Footnote ²⁹ A study compiled by the Japanese in the late 1930s offered different figures, which put the total death toll at 30,898. It also stated that the hardest hit province was Shanxi, where 6,928 people died, and that the total number of patients in Guangdong province was slightly over 1,000, of whom 358 died.Footnote ³⁰ It is difficult to determine the actual number of cases, but contemporary sources show that the situation in Guangdong was actually much worse than the Japanese study indicated. In the first two weeks alone, 365 people died in Guangzhou; the death toll was so high that the city ran out of coffins. Even the official newspaper described Guangzhou as ‘a world of horror (kongbu shijie)’.Footnote ³¹

According to the Public Health Bureau of the Shanghai municipal government, the first occurrence of the 1932 cholera outbreak in China was recorded in Shanghai on 26 April of that year. Sixty-five cases were reported in Shanghai in one month. The local authorities were vigilant for two main reasons: the Yangtze River overflowed in 1931, and the military conflict between China and Japan, which broke out in Shanghai in January 1932, killing 6,000 civilians and leaving over 10,000 missing, was only just over.Footnote ³² These natural and military disasters made the city more susceptible to the outbreak of epidemics. Second, it was unusual for cholera cases to appear as early as April and they were regarded as signs of an imminent outbreak. The government quickly identified drinking water drawn from Soochow Creek and the Huangpu River as the major cause of the epidemic and pointed out that most of those who fell victim to the disease were workers (laodongjie) who had become infected after drinking unboiled water. To prevent the disease from spreading further, the Public Health Bureau launched free vaccination campaigns and started to examine and disinfect well water.Footnote ³³ By the end of 1932, more than half a million people in Shanghai had received a cholera vaccination. An anti-cholera unit was set up to collect up-to-date information on the disease from different foreign concessions in the city. The city did not hesitate to seek international assistance. At China's request, the League of Nations sent experts to assist in health education and in organizing campaigns against cholera in refugee camps.Footnote ³⁴

The cholera cases that appeared in April 1932 not only aroused the government's attention, but also caused public alarm in Shanghai, as explicitly demonstrated in newspaper advertisements for cholera medicine. For example, an advertisement for a drug called Huladi [literally ‘enemy of cholera’] appeared in Shenbao, a leading Chinese newspaper published in Shanghai, in May 1932 and described cholera as ‘the most terrible infectious disease in the world’. The advertisement further warned that an outbreak was inevitable as the Sino-Japanese war would be followed by the hot season. ‘Huliela’ (or huyi), a term borrowed from Japanese, became increasingly accepted by Chinese people in 1932 as an equivalent term for huoluan.Footnote ³⁵ The new names huliela and huyi carried a more intimidating connotation. ‘Hu’ in Chinese means tiger. There is a Chinese proverb—‘tan hu se bian’—which means ‘Just talking about a tiger turns one's face pale’. Diseases take on new meanings when they enter new cultural environments. Cholera in early 1930s Shanghai was perceived as a by-product of the Japanese invasion and was depicted as a menace as appalling as tigers. In a propaganda campaign against cholera in Nanjing, a paper effigy of a ferocious tiger with a human in its mouth was paraded through the streets to convey the message that cholera, like tigers, devoured people.Footnote ³⁶

In early June 1932, cholera cases began to occur in Guangzhou. Two victims reportedly died within a few hours of showing symptoms.Footnote ³⁷ It is likely that the disease spread to Guangzhou via refugees and soldiers from Shanghai. When military conflict broke out in Shanghai, many refugees had fled to Guangzhou and were taken care of by an organization jointly formed by several of the city's charitable groups. The Nineteenth Army, under the leadership of Cai Tingkai (1892–1968) and comprising soldiers mainly from Guangdong province, was the major Chinese force to fight in the Sino-Japanese war. Many of them died a courageous death, and some of the surviving soldiers returned to Guangzhou when it came to an end.Footnote ³⁸

The Guangzhou government's 1932 anti-cholera campaigns emphasized the importance of individual hygiene and personal diet, as had those of the 1920s. The government extended the vaccination campaign against cholera that had begun in early summer until the end of June. Free vaccines were available in nine (later increased to 11) public and private hospitals.Footnote ³⁹ In its early stages, the government and local newspapers alike focused on cold food and drinks, particularly fruit, as the major cause of the cholera. The authorities delivered talks on transmission of the disease and warned people of the danger of consuming contaminated water and food.Footnote ⁴⁰ However, the government did nothing about providing clean water to the general public. Preventive measures mainly focused on policing food safety, such as forbidding the sale of raw fish slices, ice cream, iced drinks, overripe and cut fruit, and so on, all of which were considered highly susceptible to contamination by cholera bacteria.Footnote ⁴¹ The rationale behind these actions was that individual attention to personal hygiene, such as refraining from consuming unclean food and unboiled water, was adequate to prevent the disease.

The press played an important role in reinforcing this individual, or voluntaristic, conception of public health. Major local newspapers such as Yuehua bao, an unofficial newspaper, and the Guangzhou Republican Daily (Guangzhou minguo ribao), the mouthpiece of the Guangzhou government, featured extensive coverage of the cholera outbreak, including detailed descriptions of what the victims had eaten before they showed cholera symptoms. Interestingly, many of them were reported to have eaten fruit, lychees in particular. For example, an odd-job man working in a local post office fell sick soon after eating a couple of lychees. As soon as he returned home, he started vomiting and had diarrhoea, and died within a few hours. Another man developed the same symptoms after eating a catty (approximately 500 grams) of lychees at noon. His family called in a doctor, but treatment proved ineffective. He died that night.Footnote ⁴² The press started to propose a potential link between cholera and lychees. One report stated that, ‘news about people being infected with cholera after eating lychees appears almost everyday’,Footnote ⁴³ and another quoted a ‘prominent medical practitioner’ as saying that ‘lychees of all kinds absorb dew and mist in midnight. The water content in the white flesh [therefore] contains numerous germs.’Footnote ⁴⁴ The claim that lychees were more likely than other fruits to transmit diseases was unwarranted because all kinds of fruit are equally vulnerable to contamination by germ-carrying flies. One possible explanation for this misunderstanding is that there was a good lychee harvest in 1932 and they became a summer delicacy for many people in the city. However, the news reports prompted people to avoid taking a chance and the price of lychees dropped sharply as a result.Footnote ⁴⁵

The local press thus helped to form and spread a perception of a connection between lychees and cholera that implicitly associated cholera infection with individuals’ lack of self-control over their eating habits. As a result, individual personal hygiene was regarded as the major, if not the only, factor in contamination. This approach is in sharp contrast with the alternative of ‘environmental hygiene’, which argues that good personal hygiene is far from adequate to control epidemics and that the government should shoulder the responsibility for safeguarding public health by improving the physical living environment through measures such as supplying residents with clean water. While the local governments in Shanghai and Nanjing started to examine and disinfect well water soon after cholera cases were first reported, the authorities in Guangzhou did not do so until August 1932, two months after the cholera outbreak.Footnote ⁴⁶ In the final section, we will examine the possible reasons for the Guangzhou government's strategy of downplaying the importance of water and environmental hygiene.

Fighting the disease: charitable halls, modern medicine, and the local community

Despite the fact that the Guangzhou municipal government began to establish modern medical institutions offering Western medical treatment in the early 1920s, as explained in the first section of this paper, government hospitals did not voluntarily assume an active role during the cholera outbreak of 1932. The isolation hospital in the northern suburbs was too small to accommodate the huge number of patients and the municipal hospital refused to accept any cholera patients in the first two weeks of the epidemic, claiming that the highly infectious disease would put other patients in the hospital at risk.Footnote ⁴⁷ The private hospitals in the city did not reject patients and instead seized the opportunity to raise their medical fees. The people of Guangzhou, finding themselves left to their own devices, flocked to pharmacies for whatever medicine they believed might help. A shop owner said that he had sold over 300 doses of cholera medicine in a single day. Western medicine was less popular, though—not because people did not believe in its effectiveness, but because it was too expensive.Footnote ⁴⁸

When patent medicines proved ineffective, the majority of patients were left with no choice but to seek help from the Fangbian Hospital, a charitable hall that had been providing affordable medical services for the poor since the late Qing period.Footnote ⁴⁹ Located at High Mound (Gaogang) in the northwest of Guangzhou, the Fangbian Hospital was founded in 1899 by local merchants to offer medical care and burial services for the victims of the plague outbreak which first appeared in 1894 and resurfaced intermittently in ensuing years. It continued to operate after the plague was over and gradually developed into the most prominent of the ‘nine charitable halls’ in Republican Guangzhou.Footnote ⁵⁰ The Fangbian Hospital was widely recognized by local residents as a reliable charity organization, as reflected by the fact that a considerable number of poor people went there for affordable medical services, and the hospital raised most of its revenue through fundraising from Guangzhou people and overseas Chinese.Footnote ⁵¹ Chen Huipu (?–1947), a manager of a native bank, served as the chairman of the hospital in the early 1930s.Footnote ⁵²

As a charitable hall, not surprisingly the Fangbian Hospital failed to respond to large-scale epidemic outbreaks in a way that lived up to modern public health standards. The situation was made even worse when government hospitals shied away from their responsibilities and the Fangbian Hospital was left to fight the disease almost single-handed. When traditional Chinese prescriptions for curing diarrhoea proved ineffective (as did the Western method of saline infusion), the hospital turned to a bizarre prescription offered by someone who in fact knew nothing about medicine. The prescription was said to have been discovered by a mechanic who had tried it on his dying friend when no other medicine was available. The prescription was as follows: Put some waste yarn (which was commonly used by mechanics to clean machines) on a tile. Place the tile over a fire and wait for the yarn to turn to ashes before putting the ashes into boiled water and have the patient drink it. The prescription was introduced to the Fangbian Hospital by one of its directors about a week after the outbreak. It was reported that within three hours of the hospital beginning to use this prescription, over 20 patients in a critical condition showed significant signs of improvement in less than five minutes.Footnote ⁵³

Nevertheless, the mortality rate in the Fangbian Hospital proved that the prescription was not as effective as was claimed. On 19 June, five days after the prescription was adopted, of the 133 patients admitted to the hospital, 61 died on the same day. From 9 June to 24 June, of the 634 patients admitted to the Fangbian Hospital, 273 (i.e. 43 per cent) died and only 112 were discharged.Footnote ⁵⁴ A newspaper gave a vivid description of the frightening scene outside the Fangbian Hospital:

This deplorable situation subsequently caught the attention of the British colonial government of Hong Kong and the Health Bureau of the central government in Nanjing. On 24 June, A. R. Wellington, director of Medical and Sanitary Services of Hong Kong, went to Guangzhou to investigate. He visited the Fangbian Hospital and enquired about the prescription. A hospital director explained that because yarn alone was not very effective, they had decided to add edible salt to the prescription, which produced ‘unusually good’ results.Footnote ⁵⁶ Wellington's response is not known.Footnote ⁵⁷ On 28 June, the head of the Nanjing Health Bureau made a telephone enquiry to the Guangzhou government about the situation in Guangzhou after reading news stories about the high death rate in the Fangbian Hospital. Dr He Chichang (1890–?), head of the Guangzhou Public Health Bureau, explained that the Fangbian Hospital ‘is not a formal hospital; it is merely a local charity group whose duty is to provide medical and burial services for the poor. As for sanitation measures such as quarantine and sterilization, the hospital has made improvements with the advice [of the Public Health Bureau].’ He added that ‘the rumors [about the Fangbian Hospital] are not accurate’.Footnote ⁵⁸ The responses of the Hong Kong and Nanjing governments indicate that there were widespread accusations over the Fangbian Hospital's mismanagement of the epidemic.

To be fair, the Fangbian Hospital was not particularly ineffective if its mortality rate is compared with those of the private hospitals that treated cholera patients with Western medicine. A survey published in a medical column in Yuehua bao on 24 June shows that 36 of the 70 cholera patients admitted to the private hospitals had died by 17 June. In other words, the death rate was over 50 per cent and was seven per cent higher than that of the Fangbian Hospital.Footnote ⁵⁹ However, due to the fact that the Fangbian Hospital accepted the majority of patients who sought admission, it also, unfortunately and unfairly, bore the brunt of the blame due to its high death toll.

When medicine seemed powerless to help ward off the disease, the people of Guangzhou turned to their deities. They organized collective religious activities in the hope of getting through a difficult time together by seeking blessing from the gods. They paraded the images of their patron gods through the streets, believing that this would help to purify the community and ward off evil spirits. In the northern suburbs of Guangzhou, for example, local people took a ritual bath and abstained from meat and wine (as acts of repentance) before parading their patron god Dongyue (god of the Eastern Peak) through the community. On the day of the parade, shop owners set up shrines decorated with flowers on the street to express their reverence for Dongyue. In some places, Daoist priests were invited to perform exorcist rituals and distribute talismans.Footnote ⁶⁰ Local newspapers criticized the people for not dealing with the disease in a modern and rational way, describing their religious practices as ‘a stain on civilized society’ and ridiculing the people as ‘intellectually deficient’. The modern-minded authors who penned these articles seem to have ignored the fact that neither the government nor modern medicine had been effective in relieving the pain and anxiety of the populace during the cholera outbreak, leaving the Fangbian Hospital and horror-stricken people to their own devices.

Where were the modern medical professionals, and how did they see their role during the cholera outbreak of 1932? If the expansion of public health and state medicine implies a strengthening of the relationship between the government bureaucracy and practitioners of modern medicine, how close was their relationship in Guangzhou before and during this catastrophic cholera outbreak? As noted earlier, Western-trained doctors had been recruited to work for the government since 1912. Without doubt, the most influential person among them was the head of the Public Health Bureau. What role did he play in formulating the municipal government's public health policies? Dr He Chichang, who received his medical training in France at the Lyon Sino-French Institute from 1921 to 1927, had been the head of the Bureau since 1928.Footnote ⁶¹ He made the decision not to admit cholera patients to the municipal hospital for fear that the disease would spread to other patients. However, when he saw the number of victims increase rapidly and that the Fangbian Hospital and isolation hospital were pushed to their limits, He Chichang decided the government should take a more active role. The difficulties he encountered in implementing the policies he deemed necessary to curb the disease were huge.

In a government meeting held on 16 June, he requested that a makeshift matshed be built to serve as a temporary hospital. Instead of making a decision straight away, Mayor Liu Jiwen (1890–1957) instructed He Chichang to conduct a detailed survey on the number of patients and ordered the head of the Social Affairs Bureau to locate suitable vacant houses to accommodate patients.Footnote ⁶² It is not known whether this represented a policy of procrastination or simply reflected Liu's failure to realize the urgency of the request. Obviously not content with Liu's response, He Chichang promptly sent Liu a letter requesting that the municipal hospital be converted into an isolation hospital to admit cholera patients. He stated in the letter that:

He also asked for funding of 3,000 dollars to deal with the epidemic, assuring Liu that he would produce receipts for all expenses incurred. In the letter it is not hard to feel his anxiety and anger about the mayor's sluggishness in responding to the crisis.Footnote ⁶⁴

A turning point in the Guangzhou government's fight against the epidemic occurred on 21 June. More than two weeks after the cholera outbreak, after hundreds of patients had already died, the government finally agreed to send all the patients in the municipal hospital to private hospitals before turning the former into an isolation hospital. The task was far from easy. The Public Health Bureau had to rely on the Public Security Bureau to help escort the municipal hospital patients to private hospitals, possibly out of fear that the private hospitals would refuse to accept them. At about the same time, Sun Yat-sen University's medical school also started to admit cholera patients to its No. 2 Affiliated Hospital.Footnote ⁶⁵

Surprisingly, on 22 June, just one day after the municipal hospital began to admit cholera patients, the Medical Research Association of Guangzhou (Guangzhou yixue yanjiu hui), founded by medical practitioners and headed by He Chichang, announced that it would provide ‘the most scientific’ medical treatment for cholera patients free of charge. Comprising 29 Western medical practitioners, including doctors, pharmacists, and nurses, the Association began to operate in early July, though the worst of the epidemic had passed.Footnote ⁶⁶ It is not clear why He decided to fight the cholera through his own association when the government had agreed to admit cholera patients to the municipal hospital. If he found the government bureaucracy's inaction unacceptable, why did he not take the matter into his own hands earlier? In any case, the discord between the mayor and the Public Health Bureau was obvious. The municipal government's emphasis on building a public health infrastructure since 1912 did not necessarily mean that the Public Health Bureau and its staff exercised the power needed to fight public health crises, although, as we will see below, crises like the 1932 cholera outbreak would eventually help the Public Health Bureau to extend its influence.

Other Western-trained doctors also tried to exert the authority of modern medicine by criticizing ‘non-scientific’ prescriptions for cholera. Seeing that various Chinese medical practitioners voluntarily made available their prescriptions in newspapers, a physician specializing in obstetrics wrote a newspaper column in Yuehua bao criticizing the propagation of such prescriptions, stating that the Chinese medical practitioners involved ‘may have done this out of kindness, but those who tried the prescriptions might have been misled. . . They do not understand that patients who have the same illness may vary in degree, and that the same prescription follows different principles and serves different functions.’ He advised that medical practitioners who wanted to do good for others should be cautious in introducing medicine to the general public.Footnote ⁶⁷

The Public Health Bureau was more pointed in its criticism. A few days after the municipal hospital started admitting cholera patients, He Chichang sent letters to the unions of Western medical practitioners and Chinese medical practitioners inviting them to give their medical views on how to fight cholera. In the letter to the traditional physicians, He criticized the Chinese prescriptions that had appeared in newspapers, stating that ‘the ordinary people believed in their efficacy unconditionally and used them almost as charms’. ‘The Union of Chinese Medicine Practitioners,’ he continued, ‘is a research institution of Chinese medicine and hence should hold responsible for monitoring the profession.’ His much more courteous and positive letter to the Union of Western Medicine Practitioners noted that ‘medicine is making progress everyday. Your members must have a distinctive way of treating cholera.’Footnote ⁶⁸ The attitude of the Public Health Bureau was clear. While the modern physicians were invited to share their medical knowledge, the traditional physicians were simply asked to shut up.

Hence, the 1932 cholera outbreak revealed the tensions between the various parties that had developed since the emergence of the public health infrastructure in 1912. First, the Public Health Bureau, though an integral part of the municipal governance, had had a hard time obtaining the resources needed to cope with epidemics from the municipal government. Second, modern physicians had been trying hard to reduce the influence of the resilient traditional physicians. Given the competing agendas of these parties, their efforts to fight the cholera epidemic were thus by no means coordinated. The whole process was filled with contradictions, tensions, and ambivalence.

Due to the lack of relevant sources, it is not known how certain critical decisions in the municipal government and the Public Health Bureau were made. What is certain, though, is that the cholera epidemic of 1932 resulted in the expansion of the government's role in public health and an increase in resources allocated to the Public Health Bureau. In July, the mayor proposed sending a representative to investigate public health facilities in Western countries.Footnote ⁶⁹ In August 1935, three years after the epidemic, the government approved the construction of a new isolation hospital. The 80-bed capacity hospital was located in Jinziwan on Panfu Road in the northwest of the city, next to the Fangbian Hospital.Footnote ⁷⁰ The most far-reaching impact of the cholera outbreak on the daily lives of the poor was the change in the water supply system in Guangzhou.

Public health, urban administration, and the politics of water

The relationship between contaminated drinking water and the transmission of cholera was confirmed soon after the 1854 cholera outbreak in Britain. John Snow (1813–1858) was a British physician whose investigation of piped water in the Broad Street area of London eventually prompted the government to assume responsibility for providing clean drinking water for the poor.Footnote ⁷¹ Cholera outbreaks in China in the nineteenth century likewise caused Westerners residing in treaty ports to give serious consideration to the role of administrators in supplying clean water. According to Kerrie L. MacPherson's study, after the near-epidemic of 1890 in Shanghai, the British consul-general advocated that the private water company should become part of the municipality and that free water be provided to everyone in the British settlements, including Chinese people. The consul-general explained that a free water supply ‘would not only be a boon to the Chinese but a safeguard to ourselves as we cannot always expect the same immunity from epidemic disease which we experienced last year’.Footnote ⁷² Ruth Rogaski's study on Tianjin also shows that after the cholera outbreak of 1895, the British Municipal Council started to discuss the government's responsibility in water supply.Footnote ⁷³ Guangzhou followed the same pattern of development after the 1932 cholera outbreak. The difference in Guangzhou was that the government did not take up the responsibility voluntarily. It was not until after the populace strongly voiced its demand that the government agreed to provide free clean water to the urban poor.

By 1932, it was a well-known fact among medical practitioners in China that cholera was a waterborne disease. As soon as Nanjing was hit by cholera in late May 1932, the government began to disinfect water and spread the message in the official newspaper that, ‘Water is the conductor of cholera, it should be sterilized to prevent infection.’ The government later announced that cholera bacteria had been discovered in well water.Footnote ⁷⁴ The 1921 cholera outbreak in Guangzhou, as explained above, also shows that the Guangzhou Public Health Bureau was aware of the connection between cholera and polluted drinking water. However, at the beginning of the 1932 cholera outbreak, the Guangzhou government, just as it had done in 1921, placed the emphasis on people's unhealthy eating habits as the major cause of cholera infection. It is not unreasonable to postulate that the importance of water hygiene was downplayed because the government was neither capable nor willing to take responsibility for providing clean water to the populace, and the Public Health Bureau did not have the authority to change the government's water policy, which positioned clean water as a commodity and not a right.

It was not until 20 June 1932, when the municipal hospital finally agreed to accept cholera patients, that the Public Health Bureau began to send staff to examine well water and urge the Public Utility Bureau to grant permission to the general public to use public water taps. It is not clear what drove the Guangzhou government to change its policies. Interestingly, on the same day, the local official newspaper reported a doctor as saying that many of the cholera victims came from Upper Xiguan, a poor area in the northwestern suburbs of the city, mainly because the well water there was contaminated and the inhabitants of the area were too poor to afford running water. The doctor further urged the Public Health Bureau to request that the waterworks company install water taps in the area and open them for public use during specific time slots.Footnote ⁷⁵

This was, however, a belated response to the catastrophic cholera outbreak. The Public Health Bureau undoubtedly appreciated the importance of a clean water supply in preventing the spread of the disease, but clean running water was an expensive commodity and its supply was controlled by the Running Water Management Committee (hereafter the Water Committee), a quasi-government organization. At the request of the Public Health Bureau, the Public Utility Bureau asked the Water Committee to provide running water for public use. Three public water taps were subsequently installed in Upper Xiguan and the Water Committee promised to install more water taps for public use if necessary.Footnote ⁷⁶

In reality, the Water Committee was far from willing to open water taps for the poor free of charge. Founded in 1905 as one of the ‘new policy’ reforms implemented by Governor-General Cen Chunxuan (1861–1933), the Guangzhou waterworks company raised over half of its capital from the private sector by issuing shares. The waterworks, known as the Zengbu Waterworks, was located in Zengbu in the northwestern suburbs of Guangzhou, and the water was drawn from the adjacent Zengbu River. The waterworks company became a completely private enterprise in the early Republican era when the government sold all its shares to local merchants. Because the company was accountable to its shareholders, its water served only areas that could afford it, such as the Xiguan district, a commercial region where rich merchants lived. In 1928, a new water plant was built in the Dongshan district, a newly developed area in the eastern suburbs where numerous returned overseas Chinese and top officials resided. In 1929, the municipal government took over the waterworks company, restructured its committee, and raised the price of water tremendously, but promised that the tariff would decrease within a year.Footnote ⁷⁷

The company's change from private to public ownership did not alter the fact that it had to pay dividends to its shareholders on an ongoing basis or that water pipes were laid only in well-off areas such as Xiguan and Dongshan. Drawn from the Zengbu River, located upstream from the city and thus relatively free from potential sources of contamination, the running water then went through the processes of filtration and chlorination, and was therefore of much better quality than the water drawn from wells and rivers within the city. Hence, a clean water supply was a privilege enjoyed by only the upper strata of society. Even the Water Committee admitted in late 1931 that because of its high price, the use of running water was not common in Guangzhou. After a cut in water fees in 1931, the number of registered households increased by 3,290 in the following year. However, the proportion of residents using running water was still low. In 1932, the population of Guangzhou was estimated at about one million; only 36,800 households were registered for a running water supply. If each household comprised five people on average, the water company was serving about 184,000 people in Guangzhou, less than one-fifth of the total population. The remaining 80 per cent of the people were left with no choice but to rely on rivers and wells in the city for a supply of water. (There were about 560 wells in Guangzhou.)Footnote ⁷⁸

Was the disinfection of well water an alternative to the provision of running water? If yes, did the Guangzhou government do anything in this regard? It did not announce its plan to examine well water and to close the contaminated wells until 20 June. It was only after the cholera had subsided that the government began to distribute water disinfectants to residents in Honam, where running water was not available. Unfortunately, sources relating to the water wells in Guangzhou are scarce. From the limited sources that do exist, we know that well water in Guangzhou was generally of poor quality. Li Shufen, the first commissioner of health in Republican Guangdong once commented that, ‘none of the wells [in Guangzhou] is clean. Most of them are not deep, and there are always sewers, seeping wells and public latrines nearby.’ He concluded that well water in Guangzhou was not usable.Footnote ⁷⁹ Not to use well water did not seem to be a viable option. Why did the Guangzhou government not help disinfect well water during the cholera outbreak? A possible explanation is that Guangzhou was running out of water disinfectants at that time. It was reported that the waterworks used an extra amount of chorine to ensure that its running water was clean. As a result, the stock in Guangzhou was used up, and the stock they ordered from Shanghai had yet to arrive. The waterworks turned to bleaching powder as a last resort, even though it gave the water a strong odour.Footnote ⁸⁰

The cholera epidemic of 1932 exposed the social inequality that existed in terms of access to a clean water supply (and perhaps also access to water disinfectants). In the administrative report of the Public Health Bureau for the year 1932, the government finally admitted the importance of clean water in fighting cholera. It openly acknowledged that, ‘although there are various factors contributing to the spread of cholera, drinking water is the most crucial one. The improvement of drinking water is thus a pressing issue.’Footnote ⁸¹ This reflected a marked change from the earlier cholera discourse that laid the stress on food hygiene. Due to the change in the cholera discourse, and equally—if not more importantly—the terrible ordeal they went through in the summer of 1932, Guangzhou people's perception of water and its place in urban administration also changed. Clean water, which used to be regarded as a commodity, began to be seen as a right for all citizens. At the municipal council meeting (canyihui) held in December 1932, two councillors raised the water problem and linked it to the cholera outbreak in June. One of them contended that, ‘most of the cholera patients were poor people because their drinking water was not clean. . . [The government] should install more public water taps so that [the general public] can enjoy clean water and will not be easily infected with epidemics.’ He proposed the installation of a public water tap on every street in poor residential areas, which would supply water for six hours a day, three hours in the morning and three hours in the afternoon.Footnote ⁸² Another councillor declared that many of the cholera patients were residents of the Honam district and that the main reason they were disproportionately represented was because the rivers in the district from which local residents drew their drinking water were seriously polluted. According to him, the rivers were overflowing with garbage, sewage discharged from factories, human waste from boat people, and even animal and human bodies. He further questioned why the residents of Honam, who ‘are also citizens [shimin] and should have the same treatment’,Footnote ⁸³ were denied the right to enjoy a clean water supply.

Although providing poor people with clean drinking water for the sake of public health increasingly came to be seen as a government obligation after the 1932 cholera outbreak, the debate over whether the government was doing enough continued. In June 1933, a local executive committee of the Nationalist Party questioned the government on whether the 20-odd public water taps in the city were supplying water. It is highly likely that the committee had received complaints from residents that the water taps had been cut off. The government denied the accusation and instructed the Water Committee to install more public taps one month later. In 1934, 33 public water taps were installed in various districts of Guangzhou, the exception being the Honam district where the water plant was yet to be built. Here, the Health Bureau announced that it would distribute water disinfectants to appease the residents of the district. Nevertheless, even the municipal government admitted that the public taps might not be appropriately located. An official publication on water supply published in 1934 stated that ‘changes [in the locations of taps] need to be made after the government has found out where poor people mostly live’, and that an investigation conducted by the Social Affairs Bureau was under way. When the supply of water became an integral part of urban administration, the problem of water misuse also arose. The government discovered that some people were selling not only water obtained from public taps, but even the metal removed from the water taps, and had to issue a proclamation to forbid the practices.Footnote ⁸⁴

Due to the lack of detailed studies concerning the development of a water supply in other cities of Republican China in relation to their response to cholera outbreaks, this paper is not able to examine Guangzhou from a comparative perspective in a more in-depth manner. It is, however, important to note that supplying ordinary people with clean water for free, or at an affordable price, was neither a simple nor a smooth process, even in Western countries. Anne Hardy's study illustrates that John Snow's argument about the link between cholera and water proposed in 1849 was not accepted until 1854. However, even after 1870, people living in poor districts and even in some wealthier areas in London still faced the problem of a limited supply of water.Footnote ⁸⁵ Sometimes it was the local authorities that did not feel a sense of urgency to improve water supply. In Hamburg, Germany, as demonstrated by Richard Evans, the authorities were divided over whether a modern water filtration plant was necessary even after the cholera outbreaks of 1832 and 1848. As a result, the city was ill-equipped when it was devastated by cholera again in 1892.Footnote ⁸⁶ In short, a so-called modern medical infrastructure and medical knowledge of the connection between cholera and water did not necessarily prepare ordinary people and political authorities to respond well to cholera epidemics. We should not lose sight of the importance of local dynamics in shaping people's responses, such as the resources available, local power structures, and the different and even competing agendas of the various parties involved.