Between August 1938 and 1941, nearly 20,000 Jewish refugees from Austria, Germany and Poland arrived in Shanghai, the so-called ‘port of the last resort’.Footnote 1 They arrived at a precarious moment in Chinese history, amid the Sino-Japanese War (1937–1945) and in the immediate aftermath of the Battle of Shanghai. The Japanese invasion had displaced hundreds of thousands of Chinese civilians, shattered urban infrastructures, and placed enormous strain on the city’s already fragmented governance. In these conditions, the sudden influx of stateless refugees produced an immediate public health crisis. Overcrowded housing, malnutrition, poor sanitation, and an unfamiliar climate exposed the newcomers to various types of intestinal and respiratory diseases, as well as epidemic threats. Refugee survival quickly became not only a humanitarian concern but also a medical and administrative problem.
Yet wartime Shanghai witnessed the emergence of an improvised system of refugee medicine that functioned as both a regime of care and a mechanism of governance. Within two years, refugee physicians, municipal authorities, philanthropic elites, and both international and local aid organisations had constructed a functioning network of care, including two hospitals, outpatient clinics, a pharmacy, a laboratory, nutritional relief programmes, and epidemic control measures. This healthcare system did not simply treat disease; it organised the everyday life of a displaced population. Refugee health became a central means through which precarious lives were classified, managed, and sustained.
Despite the centrality of medicine to refugee survival, this dimension has received limited attention in existing scholarship. Shanghai’s role as a refuge has long occupied an important place in survivors’ memoirs and attracted increasing attention among historians of the Second World War, modern China, and Jewish studies. Scholars highlight circumstances of survival, community formation, diaspora philanthropy, and the capacity of refugees to rebuild social life under Japanese occupation.Footnote 2 Yet this literature often treats the refugee community as a largely self-contained social world, in which interactions with municipal authorities, other foreign residents, and the Chinese population appear only at the margins.Footnote 3 Medicine, in particular, has rarely been examined as a central dimension of refugee life.
Historians of medicine in modern China, meanwhile, have largely examined medicine as an instrument of modernisation, state-building, and colonial power. Their work has traced the spread of biomedicine through missionary activity, colonial institutions, and public health administration, as well as its encounters with Chinese medicine.Footnote 4 Refugee physicians have seldom appeared as significant actors in these processes. The history of Jewish refugee medicine in Shanghai therefore sits at the intersection of two historiographies that have rarely been brought into dialogue.
This article seeks to bridge that gap by examining ‘refugee medicine’ practised in Shanghai in two related senses. The first is institutional: the clinics, hospitals, sanitation campaigns, and nutritional programmes that refugee physicians administered under conditions of displacement. The second is epistemic: the medical knowledge that emerged from exile itself, shaped by encounters with new diseases, material scarcity, and Chinese medical traditions. Attending to medicine helps illuminate what Peter Gatrell terms ‘refugedom’–not only the political or legal condition of displacement, but the embodied, clinical, and intellectual dimensions of what it meant to live and practise as a refugee.Footnote 5 The Shanghai case suggests that exile, far from severing medical knowledge, generated new forms of knowledge that were hybrid, improvised, and grounded in intercultural encounter. Refugee physicians occupied a distinctive position within this process. They stood simultaneously inside the Chinese disease milieu, sharing its wartime pathogens and epidemiological rhythms, and outside it, as European practitioners confronting an unfamiliar climate and medical tradition. It was precisely this dual position, at once participant and stranger, that made exile a site of medical knowledge production rather than simply its interruption.
The Shanghai case also speaks to scholarship on humanitarianism and the governance of vulnerable populations. Didier Fassin has described how modern politics increasingly manages precarious lives through institutions of care, a mode he terms ‘humanitarian government’. Shanghai complicates this framework. With its tripartite jurisdictional structure, the city had long lacked a unified system of public health administration. Following Japan’s occupation of the International Settlement in December 1941, its limited involvement in refugee public health and the internment of many established physicians further weakened conventional structures of care, creating an institutional vacuum that refugees themselves came to fill. Exceptionally well-trained as physicians and organisationally supported by the JDC, they became simultaneously the governed and the governing. They were politically stateless, yet professionally and institutionally equipped to organise and administer a refugee healthcare system. This inversion distinguishes the Shanghai case from both colonial public health regimes and postwar refugee regimes, in which displaced populations remained primarily recipients rather than administrators of humanitarian care.
Drawing on archival records, memoirs, newspapers, and medical journals in multiple languages, this article traces the evolution of refugee medicine in wartime Shanghai in both its institutional and epistemic dimensions. It shows how an improvised emergency response gradually evolved into an integrated regime of care that was neither purely communal nor purely philanthropic, but sustained through continuous negotiation among refugee organisations, municipal authorities, transnational aid agencies, occupation authorities and local medical institutions. In managing refugee health, these actors produced an early, historically overlooked form of humanitarian government, one that both provided relief and regulated a precarious population. The resulting system, ‘curtailed and modest but adequate’ as contemporaries described it, extended well beyond the refugee community itself.Footnote 6 It alleviated structural shortages in Shanghai’s medical landscape by providing affordable care to underserved low-income foreign residents, coordinating dispersed medical resources during wartime, and creating opportunities for medical exchange between refugee physicians and Chinese practitioners. Rather than representing a temporary humanitarian response, refugee medicine left durable legacies that reshaped healthcare provision in Shanghai.
The article proceeds in four parts. It first situates the arrival of European refugees within Shanghai’s wartime public health crisis, showing how their management built upon administrative experiences originally developed for displaced Chinese civilians. It then traces the formation of an integrated refugee healthcare system between April 1939 and December 1941 under the leadership of the Committee for the Assistance of European Jewish Refugees in Shanghai (CAEJR). The article’s third section examines the critical transition following the outbreak of the Pacific War and the dissolution of municipal authorities, when the Joint Distribution Committee (JDC) intervened directly in medical relief under Japanese-imposed constraints and refugee physicians assumed genuine leadership as primary care providers. The last section explores how exile itself became a site of medical knowledge production, examining how refugee physicians adapted to Shanghai’s disease environment and collaborated with Chinese practitioners within a pluralistic therapeutic landscape.
An emerging crisis for a shifting public
A major treaty port since the First Opium War (1839–42), Shanghai had developed into a global metropolis that hosted successive waves of migrants, sojourners and refugees. The city was also defined by a distinctive structure of divided sovereignty. By the early twentieth century, Shanghai was partitioned into the International Settlement, the French Concession, and the Chinese-administered districts including Wusong, Jiangwan, Nandao, Pudong, and Zhabei. These jurisdictions operated under separate administrative institutions, legal systems, and fiscal regimes. Public health governance was correspondingly fragmented, a condition that would shape the city’s response to the refugee crisis of 1938–41.Footnote 7
Before the influx of Jewish refugees during the Second World War, Shanghai already hosted two established Jewish communities, each shaped by distinct historical circumstances. The first consisted of Baghdadi Jews who had arrived during the nineteenth century alongside British commercial expansion from India. Largely affluent, English-speaking merchants, they had established themselves firmly within the International Settlement. The second consisted of Russian Jews, many of whom had first settled in Harbin before the 1917 Russian Revolution and later relocated to Shanghai following the Japanese takeover of Harbin in 1932. They remained predominantly Russian-speaking and settled primarily in the French Concession.Footnote 8 The arrival of Central European Jews between 1938 and 1941 introduced a third and socially distinct refugee population. Most were Austrian, German, and Polish Jews who fled the escalating Nazi persecution in their home countries.Footnote 9 The vast majority arrived in Shanghai by sea, as alternative destinations became increasingly inaccessible, culminating in the 1939 British White Paper that severely restricted legal Jewish immigration to Palestine.Footnote 10 With passport control in Shanghai effectively suspended after 1937, the city had become one of the few remaining ports open to Jewish refugees anywhere in the world. The refugee population had grown rapidly, rising from approximately 1,500 in late 1938 to nearly 17,000 in late 1939.Footnote 11 They constituted the last cohort of ‘Shanghailanders’, a term of self-identification among the city’s foreign residents, though unlike their predecessors, they had little opportunity to enjoy colonial privileges associated with that status. Instead, they experienced Shanghai primarily through the hardships of wartime displacement.Footnote 12
By the time the central European refugees arrived, Shanghai was already struggling to accommodate displaced populations. Since the early 1930s, catastrophic flooding and the outbreak of the Sino-Japanese War had driven hundreds of thousands of Chinese civilians into the city, while approximately 30,000 White Russians had also settled there by 1940, many only intermittently employed and widely regarded as ‘a burden to the community’.Footnote 13 Years of managing mass displacement had convinced the Shanghai Municipal Council (SMC), the elected governing body of the International Settlement, that refugee influxes could pose serious public health challenges. Its records repeatedly linked population displacement to epidemic disease, with cholera deaths among Chinese residents rising sharply in 1932 and 1938.Footnote 14 When European Jews began arriving, the Chinese-administered districts and peripheries of the International Settlement had already fallen under Japanese occupation, while the International Settlement had become the principal refuge for displaced Chinese civilians. In early 1938, more than 90,000 Chinese refugees were housed in over 150 camps within the Settlement alone, with thousands more living in alleyways and abandoned buildings. Camp inspections, sanitation regulation, vaccination campaigns, and epidemic surveillance had by then become routine tasks of municipal governance.Footnote 15
This prior experience proved critical in shaping how municipal authorities approached the Jewish refugee influx. Much of the existing scholarship treats Jewish refugees in Shanghai primarily as an isolated population. From the perspective of municipal governance, however, their arrival represented less an unprecedented crisis than the incorporation of a new population into an existing regime of wartime refugee management. Administrative practices developed in Chinese refugee camps, particularly the coordination between municipal departments and charitable organisations, provided an institutional template for the governance of Jewish refugee housing, sanitation, and healthcare.
At the same time, years of refugee relief had exposed the limits of municipal capacity. Although the Central European refugees numbered no more than 20,000, they arrived at a moment when the SMC’s administrative and financial resources were already under severe strain. Public health obligations were unevenly distributed across Shanghai’s jurisdictions, while the Japanese occupation of the Chinese districts further complicated urban governance. Most European refugees settled in Hongkou, an overcrowded, war-damaged district that lay at the intersection of multiple administrations, none of which assumed full responsibility for their welfare. The SMC therefore drew a clear boundary between its municipal obligations and responsibility for this new refugee population. It designated sites for refugee camps and cemeteries, requiring that at least one camp include an isolation hospital.Footnote 16 Entry into the International Settlement was further regulated through financial requirements. Adult refugees, unless they had an immediate relative in Shanghai, intended to marry someone already there, or held a contract for a job in Shanghai, were required to possess at least US$400 in available funds. These measures limited the Council’s direct financial responsibility and left the long-term provision of refugee relief and welfare largely to Jewish organisations.Footnote 17
In practice, the Committee for the Assistance of European Jewish Refugees in Shanghai (CAEJR) emerged as a quasi-administrative authority, organising refugee relief within the Jewish community rather than through municipal welfare. Established in 1938 by Shanghai’s Jewish community, the CAEJR bore responsibility for social and financial management of refugees, while the SMC retained discretionary power over permits, policing, and sanitary oversight.Footnote 18 With financial support from the JDC expanding dramatically between 1938 and 1939, the CAEJR organised housing, food distribution, and medical care within this framework.Footnote 19
The scale of need was considerable. The refugee population included professionals such as physicians and lawyers, but most had fled Europe in haste, bringing few possessions and limited financial resources. By the end of 1939, more than 6,500 refugees relied on meals provided by the CAEJR. As the war progressed and economic conditions deteriorated, relief dependency rose steadily, from 10,168 individuals in January 1940 to 13,447 in December 1940.Footnote 20 While a few better-off families settled in the French Concession, the vast majority were housed in Hongkou district, concentrated in the five Heime (‘Emigrants’ Homes’) established by the CAEJR. Living conditions in the Heime were harsh. Converted from buildings that had survived the bombardment, including two schools, a barracks, a warehouse, and the ruins of five bombed houses, the Heime offered little comfort or dignity.Footnote 21 When Laura Margolis of the JDC visited in May 1941, she found approximately 2,500 men, women and children still living in these shelters. In the old barracks, two antiquated toilets served roughly 400 residents. Margolis was shocked ‘to see these people living in such poverty and squalor’.Footnote 22
The vulnerability of this refugee population to disease was immediately recognised by leaders of the Jewish community. Many refugees arrived already suffering tuberculosis and psychological trauma following the ordeals of flight.Footnote 23 Shanghai’s humid climate, dense population, and uneven sanitary conditions had long made the city prone to epidemic disease, prompting the SMC Health Department to maintain monthly surveillance of recurring outbreaks of cholera, smallpox, diphtheria, scarlet fever, typhoid, dysentery, and measles. Shortly after landing, the new arrivals experienced a minor outbreak of Salmonella enteritis. As one established foreign resident observed, the refugees were ‘probably more liable to sickness than those who have been hardened by years of residence in Shanghai’.Footnote 24 The remark also revealed how longer-settled Shanghailanders positioned themselves simultaneously as European in their hygienic standards and as locally acclimatised.
Initial responses to refugee health drew on existing medical infrastructure. In 1938, when refugee numbers remained manageable, patients were treated in municipal and private hospitals, including the B’nai B’rith Polyclinic and Hospital.Footnote 25 As the refugee population surged in 1939, however, it became clear that they needed dedicated facilities. The International Committee for Granting Relief to European Refugees in Shanghai (IC), under the leadership of Paul Komor (1886–1973), converted a building on Whashing Road to the ‘Emigrants’ Hospital’, which began receiving patients in January 1939. With sixty beds, the hospital treated a wide range of conditions including internal, neurological, dermatological, ophthalmological, and venereal diseases, and performed minor surgical procedures.Footnote 26 To provide more systematic oversight, the CAEJR founded its Medical Board in March 1939 to supervise the hospital’s administration and staffing, and to identify refugees eligible for free treatment and medication.
The inadequacy of this system became apparent during the scarlet fever outbreak in the spring of 1939. The epidemic lasted two months and peaked at 128 daily cases. Although it was brought under control with only two deaths recorded, it served as a critical warning of the risks posed by concentrated refugee populations. Notably, in a city where access to medical resources and disease outcomes generally reflected racial hierarchies, this episode produced a striking inversion: more cases were recorded among foreigners than among Chinese residents.Footnote 27 While the overall death toll remained low, this reversal underscored the particular vulnerability of the new arrivals and alarmed the broader foreign community.
The epidemic proved a key turning point. It demonstrated that the refugees’ medical problems could neither be contained within the Jewish community nor handled by individual relief organisations. As the refugee population grew rapidly, new waves of illness exposed the inadequacy of existing medical facilities. It became increasingly clear, both within and beyond the Jewish community, that an effective response required coordination across ethnic and organisational boundaries.
The crisis also exposed structural shortages in Shanghai’s medical landscape. The city possessed a substantial number of trained physicians, but lacked sufficient hospital capacity, particularly for lower-income patients. In 1936, the city had approximately 7,000 registered doctors, including 3,000 doctors of traditional Chinese medicine and 4,000 doctors of Western medicine.Footnote 28 That same year, Shanghai’s 108 hospitals offered 9,000 patient beds, a significant portion of which were reserved for elite institutions or priced beyond the reach of ordinary citizens. For poorer members of the foreign community, medical care was either inaccessible or prohibitively expensive, while linguistic and cultural barriers limited access to Chinese medical practitioners. As multiple Shanghailanders warned, the rising cost of illness had become a burden for ‘a great many foreign residents’ in the city.Footnote 29
Yet the arrival of refugee physicians did not simply alleviate these shortages. Instead, it exposed a striking mismatch between medical expertise and medical need. Among the refugees were some of Europe’s most highly trained physicians, who entered an already saturated market for elite Western medical services. In treaty ports such as Shanghai and Xiamen (Amoy), that market was already occupied by British and American physicians, missionary doctors, and a growing cohort of Western-trained Chinese practitioners.Footnote 30 As German Jews began arriving in Shanghai from 1933 onwards, the high proportion of physicians among the newcomers attracted the attention of both the Shanghai Municipal Police and the German Consulate. The German Consul warned Berlin that ‘it would be unwise for any further Jewish practitioners to come here since there are too many doctors of all nationalities striving to make a living at present’.Footnote 31 As a result, many refugee physicians found themselves unable to practise due to professional restrictions and limited institutional openings. Of approximately 200 refugee doctors in Shanghai, only about 40 secured either regular institutional appointments or a viable private practice.Footnote 32
In this context, the Medical Board evolved beyond an administrative body into a work-relief programme. It sought to employ refugee doctors within its own facilities or place them in positions elsewhere, including in the Chinese interior. Some newly qualified physicians worked in Shanghai’s Western hospitals and gained firsthand experience with local and tropical diseases, while others were integrated into expanding medical services for the Jewish refugee population.Footnote 33 Although the income they earned rarely provided a sufficient livelihood, many refugee physicians nevertheless continued serving fellow refugees. Over time, they increasingly extended their practice beyond refugee networks to Shanghai’s broader foreign population. Over the years that followed, the programme reshaped Shanghai’s medical landscape by linking refugee medical expertise to unmet demand among both refugees and lower-income foreign residents.
The scarlet fever outbreak also catalysed institutional integration, prompting more coordinated governance over refugee health. Prior to 1939, relief work was carried out by a patchwork of organisations divided along lines of religious affiliation, language, and professional background, further complicated by the city’s jurisdictional fragmentation. The CAEJR, anchored by Shanghai’s established Sephardi Jewish elite, worked closely with the SMC, the French Municipal Council, and the JDC’s offices in New York and Paris.Footnote 34 Alongside it, the IC, which had been established two months before the CAEJR, relied on the organisational experience and philanthropic networks of Shanghai’s Hungarian, Czech and Austrian communities. The two committees increasingly drew on complementary strengths, combining the CAEJR’s ties to municipal and international bodies with the IC’s hands-on relief infrastructure and maintenance of the refugee registry. The scarlet fever epidemic gave this convergence institutional form.Footnote 35
By late 1939, the Medical Board of the CAEJR had become a central coordinating office, bringing together representatives of the CAEJR, the IC, and the JDC.Footnote 36 Komor, who had initiated the Board’s founding as secretary of the IC, proposed Frederick Reiss, a physician who had resided in Shanghai since 1922, as its chairman.Footnote 37 Other members included the Austrian physician Egon Pribram, who arrived in Shanghai in April 1939; Dr. Selig-Toms, representing the IC; and internists such as Dr. Horst Lange, who had come to Shanghai in 1933 following Germany’s enactment of the Law for the Restoration of the Professional Civil Service (‘Gesetz zur Wiederherstellung des Berufsbeamtentums’).Footnote 38 The Board thus combined long-standing local experience with newly arrived expertise. Supported by Jewish philanthropists, it expanded its responsibilities beyond clinical care to oversee the Emigrants’ Hospital, sanitation across the five Heime, and medical training within the refugee community. In doing so, it became the institutional intermediary linking municipal authorities, international organisations, and refugee professionals.Footnote 39
The refugee crisis thereby brought broader segments of Shanghai’s international community into a coordinated public health undertaking. Concerns about infectious disease, rising medical costs, and insufficient hospital capacity converged, prompting calls for expanded and more inclusive health services. In April 1939, leaders across Shanghai’s foreign communities came together to found the European Emigrants’ Associated Hospitals for Shanghai. Overseen by an international committee of ‘leading citizens’, the initiative sought to translate growing demands for coordinated and more inclusive healthcare into an institutional programme. Its blueprint called for a modern hospital with 200 beds for non-infectious cases and 150 for infectious cases, designed to serve both refugees and the broader community.Footnote 40 Efforts to provide hospital care for European refugees were justified not only on humanitarian grounds but also as a long-overdue solution to the shortage of affordable medical care for low-income foreign residents.
The refugee crisis also exposed the instability of the very notion of ‘the public’ in wartime Shanghai. Municipal discourse initially framed the refugee influx as a threat to Shanghai and to ‘the international community’, yet these categories remained fluid and contested. Protective measures were calibrated primarily to safeguard rate-paying residents within the International Settlement south of Soochow Creek, while responsibility for refugees residing elsewhere was displaced onto communal or international organisations. At the same time, debates in local newspapers and among relief organisers invoked humanitarian language that transcended nationality and race, appealing to ‘Shanghailanders of all nationalities’.Footnote 41 The result was a layered and shifting conception of the public: at times fiscal and jurisdictional, at times moral and humanitarian. Refugee health thus became a site where competing definitions of collective responsibility were negotiated. Public health was not merely a technical matter, but a political question of inclusion—who counted within the urban body, and on what terms.
Building the infrastructure of care, 1939–1941
The Associated Hospitals gave organisational form to this broader coalition, bringing together municipal health officials, Jewish philanthropists, and experienced relief organisers. The committee included key public health officials from the Shanghai Municipal Council (J. H. Jordon) and the French Municipal Council (Y. Palud), alongside Sephardi Jewish philanthropists including Sir Victor Sassoon and Sir Elly Kadoorie. Longtime relief organisers such as Paul Komor and Michel Speelman continued to play central roles.Footnote 42 The Sassoon and Kadoorie families, moreover, supported a broader range of refugee aid projects, from schools and vocational training to the distribution of start-up funds and medical equipment. Together, these individuals embodied the convergence of municipal, philanthropic, and communal efforts to respond to the deepening public health crisis among Jewish refugees.
Translating this ambitious vision into practice, however, required substantial and sustained funding. As one long-term Shanghai resident noted, ‘it is at present almost entirely a matter of money’.Footnote 43 The expanded committee’s principal task was therefore to mobilise overseas support and fully leverage local resources. It launched an international fundraising campaign, reaching out to prominent individuals and philanthropic institutions, including Lord Nuffield, Albert Einstein, and the International Red Cross. Unfortunately, most such efforts yielded little support, as amid rapidly unfolding international crisis ‘the Shanghai emigrants problem became of minor importance’. The American campaign initially struggled as well because of the uncertainty over the United States’ response to the rapidly expanding war in Europe. Eventually, however, the JDC began sending regular monthly remittances, which continued until the outbreak of the Pacific War.Footnote 44 Locally, the North China Daily News published a series of editorials and appeals urging ‘fellow Shanghailanders of all nationalities’ to contribute to expanded hospital facilities for the refugees.Footnote 45 Despite these combined efforts, the committee was ultimately unable to secure sufficient funds to realise the hospital system on the scale originally envisioned.
Nevertheless, the initiative laid the groundwork for a makeshift yet integrated healthcare system grounded in principles of resource sharing, centralised coordination, and increasingly broad provision of care. Sustaining this system required continuous mobilisation across multiple social networks. Funding came not only from organised Jewish institutions, but also from donations by residents and contributions from refugees themselves. By December 1940, the Committee and its partners had established 2 functioning hospitals: 1 for infectious diseases and 1 for non-infectious cases, with a combined capacity of over 200 beds (Table 1).
Jewish refugee medical infrastructure in Shanghai, 1939–1940
Table 1. Long description
The table consists of six columns and multiple rows categorized by service type.
* Inpatient facilities:
- Emigrants’ Hospital, established Jan. 1939 at Whashing Road then Ward Road Heime. Had 110 beds by end of 1940. First central refugee hospital for general medical and minor surgical cases.
- Isolation hospital, established Sept. 1939 at Chaoufoong Road Heime. Had 125 beds by end of 1940. Originally for scarlet fever quarantine.
* Outpatient facilities:
- Outpatient departments, established Apr. to Nov. 1939 across multiple Heime (Ward Rd., Chaoufoong Rd., Kinchow Rd., Alcock Rd., Pingliang Rd.) and S J Y A School. Provided day and night consultations and free medicine.
- Polyclinic: Provided specialist consultations 2 to 3 times per week for internal medicine, psychiatry, dermatology, and neurology.
* Medical supplies: Central pharmacy, established Mar. 1940 at Kinchow Rd. Heime. Supplied free medication and standardized prescriptions.
* Maternity care: Mount Moriah Maternity Ward, established Feb. 1940 at Ward Road Heime. Recorded 10 live births and 8 stillbirths in the first 2 months.
* Laboratory services: Medical laboratory, established Dec. 1939 at Ward Road Heime. Provided routine and advanced diagnostics like blood sugar and bilirubin.
* Dental care: Dental clinic at Ward Road Heime providing free treatment.
* External supporting facilities:
- Shanghai General Hospital: Major surgeries until Dec. 1939.
- Shanghai Sanitarium Clinic: Major surgeries after Dec. 1939.
- Shanghai Country Hospital: X-ray services.
- Chinese Red Cross and Russian Hospital: Mental illness support.
- B’nai B’rith Hospital: Diathermy and financial aid.
- Shanghai Children’s Hospital: Paediatric beds.
- The American Foundling-House (The Cradle): Infant shelter.
The Isolation Hospital illustrates how rapidly this improvised system responded to changing epidemiological conditions. During the scarlet fever outbreak of spring 1939, the Medical Board established an isolation ward to quarantine affected patients, followed a couple of months later by a summer hospital. These facilities were tested by an outbreak of intestinal disease later that year. The hospital recorded a death rate of only 1%, significantly below that recorded in comparable outbreaks in the International Settlement and dramatically below the 25.5% mortality rate documented during a dysentery epidemic in California the same year. Expanded to a capacity of 103 beds by April 1940, the Isolation Hospital admitted patients suffering from a wide range of infectious diseases, among them intestinal conditions (amoebic and bacterial dysentery, diarrhoea, enteritis, typhoid fever, paratyphoid fever and stomatitis-related diarrhoea), respiratory illnesses (influenza, measles, diphtheria and pulmonary tuberculosis), and other contagious diseases including scarlet fever, epidemic typhus, chickenpox, malaria, erysipelas and trachoma. Chronic cases, including diabetes and skin diseases, were also accepted.Footnote 48
Disease patterns shifted noticeably in the first six months after the main refugee influx. Between August 1939 and March 1940, intestinal illnesses declined as the refugee population became increasingly acclimatised to local climatic and dietary conditions. Respiratory infections, by contrast, exhibited a steady upward trend. This contrast between the initial spike and subsequent decline in digestive disorders, and the growing incidence of respiratory disease, is illustrated in Figure 1.
Isolation hospital cases summary (August 1939–March 1940, major intestinal and respiratory diseases).
Figure 1. Long description
The X axis lists months from Aug-39 to Mar-40. The Y axis represents case counts from 0 to 60.
* Diarrhoea and enteritis: Starts at 8 in August, peaks sharply at 49 in September, then declines steadily to 4 by March.
* Dysentery bacillary: Starts near 0, peaks at 28 in September, then fluctuates downward to 6 by March.
* Tuberculosis of the respiratory system: Remains low between 0 and 5 until November, then rises slightly to peak at 12 in March.
* Pneumonia: Increases gradually from 0 in August to a peak of 16 in November, then plateaus and ends at 12 in March.
* Diphtheria: Remains near 0 until October, then rises to a peak of 17 in January and February, ending at 16 in March.
* Influenza: Remains at 0 until November, then rises to 11 in February and ends at 4 in March.
As the refugee medical system matured, clearer guidelines were introduced to define the respective roles of the two hospitals. The Isolation Hospital admitted patients with highly contagious diseases such as smallpox, diphtheria, typhoid, whooping cough, spinal polio, epidemic meningitis, and open tuberculosis. By 1941, dysentery was no longer considered to require strict isolation and was transferred to the Emigrants’ Hospital for treatment.Footnote 49 Such adjustments show how refugee physicians gradually adapted their medical practice to Shanghai’s disease environment, translating accumulated clinical experience into revised classifications of disease and a more selective allocation of limited institutional resources.
Beyond clinical care, the Associated Hospitals oversaw a range of public health initiatives, including vaccination campaigns, first-aid training, routine medical check-ups for schoolchildren, and hygiene maintenance across the Heime. Dr. Salomon, for instance, managed health services at the S.J.Y.A School, where he conducted X-ray screenings at the start of each term, recorded the results of physical examinations, and coordinated tuberculosis vaccinations.Footnote 50 Sanitation across the Heime was an ongoing concern. When the SMC established the first Ward Road Heime, it installed bathing facilities and flush toilets that, while modest, far exceeded the prevailing local standards in Hongkou.Footnote 51 After the refugees arrived, the Medical Board conducted regular inspections to identify urgent sanitary needs. Medical and health guidance was also disseminated through community channels. The Shanghai Jewish Chronicle, for instance, published ‘Twelve Golden Rules for Good Health’, which advised readers to drink only boiled water and to keep their heads covered in strong sunlight, among other precautions.Footnote 52 First-aid training courses organised by the Medical Board also prepared refugees to manage emergencies with limited resources, a capacity that would prove particularly important as wartime conditions deteriorated.
Over time, the Medical Board drew increasingly on the skills of refugee physicians and medical specialists, while also soliciting voluntary assistance from established practitioners in Shanghai. Refugee doctors not only provided frontline care but assumed key administrative roles. Dr. Otto Freund, initially director of the Kinchow Road Outpatient Department, later took charge of supervising the Emigrants’ Hospital. Dr. Theodor Friedrichs emerged as a central figure both in Shanghai’s medical scene and within the refugee community, which was soon to face far greater challenges. By the eve of the Pacific War, refugee physicians had thus become embedded not only in the clinical work of the system but also in its administration, positioning them to assume greater responsibilities when its external supports began to collapse.
Medical relief under Japanese occupation, 1941–1945
The outbreak of the Pacific War fundamentally transformed the institutional environment within which refugee medicine operated. Before December 1941, the International Settlement and the French Concession had remained outside direct Japanese control, preserving a functioning colonial infrastructure through which refugee organisations collaborated with municipal authorities and foreign institutions. Japanese takeover of the International Settlement soon ended this arrangement and subjected Allied nationals to increasingly restrictive measures, culminating in the internment of more than 6,000 Allied civilians from early 1943.Footnote 53 This changing political landscape had far-reaching implications for refugee life and healthcare. Prominent Jewish patrons such as the Kadoories were subjected to Japanese detention and control, while many long-established Jewish physicians were interned. At the same time, overseas financial support became increasingly precarious. The JDC, which had long financed refugee relief in Shanghai, consequently assumed a more direct role in its administration and coordination.Footnote 54 As established institutions weakened, relief increasingly depended on resources within the displaced refugee community itself. Under these straitened circumstances, the labour, initiative, and medical expertise of refugee physicians became indispensable to the reconstruction of refugee healthcare under Japanese occupation.
When Laura Margolis arrived in Shanghai in May 1941, she encountered a relief system already under severe organisational strain. Dispatched by the JDC to assess local conditions, Margolis and her colleague Manuel Siegel sought to ‘bring some order out of this chaos’.Footnote 55 Of the 20,000 Jewish refugees in Shanghai, an estimated 12,000 resided in Hongkou, and 8,000 of these had been certified as in need of relief, which meant access to a single daily meal from the community kitchen consisting of a bowl of soup and nine ounces of bread.Footnote 56 By January 1942, the Committee had to cut in half the number of refugees receiving aid, from 8,000 to 4,000. Only children, the elderly, the sick, and those suffering from severe malnutrition remained eligible for the daily ration of a bowl of stew.
The relief committee, which employed 500 workers across five Heime and a central administrative office, operated essentially as a work-relief programme that was no longer financially viable. In early 1942, Margolis and Siegel revealed to the employees, ‘by plain arithmetic’, that it was impossible to provide relief and pay staff salaries, which remained meagre even by Shanghai standards.Footnote 57 The established Sephardi Jews by this point were increasingly unable to provide either financial support or administrative leadership. The outbreak of the Pacific War severed JDC’s direct financial and communication links with Shanghai, making the transfer of funds from New York virtually impossible.
In response, Margolis and Siegel organised a new local committee composed of French, Swiss, long-resident German Jews, along with a small number of active refugees, including Theodor Friedrichs, who contributed vital medical expertise and organisational support. Operating under severe constraints, the new committee worked on a day-to-day basis, constantly recalibrating relief around whatever limited funds were available. Captain Koreshige Inuzuka (1890–1965), the Japanese naval officer then overseeing refugee affairs, preferred dealing with the JDC representatives rather than with the original Committee dominated by Shanghai’s ‘leading citizens’. Following negotiations with Margolis, Inuzuka authorised the release of 5,000 bags of cracked wheat donated by the American Red Cross, unfroze the Shanghai Committee’s remaining funds, and permitted Margolis to borrow money locally from neutral parties.Footnote 58 Despite these efforts, the committee was forced to reduce the number of refugees receiving aid and cut expenses across the board. Registration of new refugees ceased entirely.
In a desperate attempt to reduce salary costs, both the Emigrants’ and Isolation Hospitals were closed on 30 June 1942. The SMC subsequently agreed to care for Jewish refugees with infectious or mental illnesses, but only those residing within the International Settlement. The CAEJR negotiated parallel arrangements with French Concession authorities, though general healthcare needs went largely unmet.Footnote 59 Beginning in the summer of 1942, the primary agency coordinating relief was the ‘Kitchen Fund’ established by Margolis and Siegel, which assumed oversight of medical services in addition to food distribution. Medical provision under the Kitchen Fund was only a fraction of what had existed between 1939 and 1941.
The consequences became rapidly apparent. The summer of 1942 witnessed more refugee deaths than the preceding two years combined, driven by deteriorating nutrition and a growing number of refugees suffering from chronic diseases. In August 1942 alone, thirty-one refugees died, and many mourners fainted from the heat during funeral services.Footnote 60 Alarmed by the rising number of obituaries, refugee physicians within the Kitchen Fund pooled their remaining resources and began planning a new medical facility.
The Shanghai Refugee Hospital (SRH), established in early 1943, became the community’s central hospital and remained the sole refugee hospital until 1949. The Kitchen Fund gradually expanded the Hospital over the following years. By 1945, the hospital comprised 140 beds across four departments: internal medicine, surgery, tuberculosis, and maternity. During the wartime emergency, the hospital’s services extended to all those in need, Chinese and foreigners alike.Footnote 61 Between June 1944 and March 1945, the hospital admitted between 135 and 151 patients per month and discharged between 120 and 140. In July 1945, amid extreme heat and intensified military operations, the hospital received 198 patients.Footnote 62 Access to care was regulated by the Kitchen Fund: refugees first had to be approved for aid before being sent to the hospital’s outpatient clinic for treatment.Footnote 63
In February 1943, the refugee community faced a further ordeal. Japanese authorities mandated the forced relocation of stateless refugees to a small ‘Designated Area’ in Hongkou, an already overcrowded district of approximately three square kilometres that housed over 100,000 Chinese residents and 8,000 Jewish refugees. The relocation involved 16,000 refugees, pushing population density to extreme levels and placing all available infrastructure under acute strain.Footnote 64 To make matters worse, Margolis and Manuel Siegel were detained by the Japanese authorities. Relief work nonetheless continued under the Committee that Margolis had helped establish, and the SRH became increasingly indispensable.
During the summer of 1943, the hospital proved critical in responding to outbreaks of dysentery, typhoid, malaria, and typhus. At least 89 Chinese and foreign residents died of such illnesses in the last week of May 1943 alone. Among the Jewish refugee patients, the mortality rate reached nearly 30%, exacerbated by severe shortages of medical staff and accommodation.Footnote 65 Despite these constraints, the hospital and its outpatient clinic remained active. The latter recorded approximately 1,500 patient visits in June 1943, and by June 1944, that figure had climbed to 10,618. This dramatic expansion reflected both the deteriorating health conditions in Hongkou and the hospital’s growing role as the principal medical infrastructure sustaining the refugee community in the hardest years.Footnote 66
Conditions in the confined Hongkou area were dire. Daily food intake for refugees provided fewer than 1,300 calories, barely sufficient to prevent acute starvation.Footnote 67 The winter of 1943–1944 brought further hardship. Restrictions on electricity and a shortage of coal made it nearly impossible to heat homes, and the combination of cold and hunger compounded the community’s vulnerability.Footnote 68 The JDC would later describe the years 1943–1944 as ‘the most dark period seen from the medical point of view’.Footnote 69 In the final eight months of 1943, the hospital treated 148 cases of sprue and avitaminosis, 51 of whom died; and an additional 300 similar cases were treated in the outpatient clinic.
At this critical juncture, refugee physicians played a decisive role in addressing the nutrition crisis. A group of Jewish doctors had established the Hongkew Physicians’ Association as early as October 1939, and its registered members received special travel passes in and out of the Designated Area from Ghoya Kano, the Japanese official who oversaw affairs of stateless refugees. Seizing this opportunity, the Association’s physicians sought to raise awareness among relief organisations and the larger public of the refugees’ deteriorating health conditions. On 20 December 1943, the Association organised a high-profile lecture on sprue at the Kadoorie School auditorium, attended by representatives of Jewish organisations and the press. The Association urged the JDC to increase calorie and vitamin content of refugee diets and to ensure sufficient food provision.Footnote 70 This recommendation was adopted, with malnourished refugees receiving an additional daily meal and children and the sick receiving supplemental milk. As a result, the incidence of sprue, which had reached a morbidity rate of 43.7% in 1943, declined significantly. By the summer of 1944, the disease was largely under control.Footnote 71 Funds transmitted via the Red Cross further enabled the committee to improve both dietary provisions and medical services for the refugee population.
Wartime circumstances also posed immediate threats to physical safety. In 1944, Japanese authorities mandated the construction of air-raid shelters and organised nighttime drills. These shelters were shallow and cramped, barely allowing occupants to stand upright. One refugee, Judy Urman, recalled a particularly harrowing night when all residents were ordered to move to the lower floors. Dressed only in nightclothes, they shivered from prolonged exposure to the cold. Urman developed a severe cough from that night, followed by diarrhoea and high fever.Footnote 72 On 17 July 1945, American aircraft bombed Hongkou, causing casualties among Chinese civilians and Jewish refugees. Outpatient visits surged from 11,077 in March to 15,216 in July, and hospital admissions rose from 141 to 198.Footnote 73
The emergency training organised in earlier years proved effective during the bombing. Within moments of the attack, volunteers rushed to bandage wounds, carry stretchers, guard property, and organise relief efforts. Dr. Friedrichs recalled that even with electrical and telephone lines severed, medical personnel continued working by candlelight to complete critical medical interventions before nightfall.Footnote 74 Makeshift first-aid stations quickly emerged, where, as Dr. Herbert Greening noted, many women previously trained through Medical Board courses played a significant role in administering aid.Footnote 75 Chinese residents also joined rescue efforts, helping carry bodies, apply bandages, and distribute water. By the end of the day, five Jewish refugees had been killed and nearly thirty wounded. As Rena Krasno later recalled, ‘All the injured, whether refugees or Chinese, received medical attention without racial distinction … even beggars received treatment just like everyone else’.Footnote 76 In that moment, the vision articulated years earlier by the Associated Hospitals committee, to provide care ‘without distinction of race or creed’, was realised on the ground, even as the committee itself had long since ceased to function.
The worst-case scenario Laura Margolis had predicted in January 1944 did not ultimately materialise. Reflecting on rising mortality since her arrival, she had written grimly:
In 1940 the death rate was 139. In 1941 it was 182, and 1942 it was 350. In 1942 the death rate had practically doubled that of the previous year. 1942 was a typhus year. We don’t know the death rate for 1943, but I can guarantee you that 1944, being an alternate year of 1942, and every other year is a typhus year, will have a death rate four or five times as great as it was in 1942. I have the greatest respect for the courage and the will to live which those people have shown.Footnote 77
Her prediction, while sincerely felt, was likely also calculated to generate urgency and mobilise additional funding from abroad. In the event, the toll was severe but not catastrophic (Table 2). These losses did not follow the upward trajectory Margolis had anticipated. Annual deaths fell from 1943 to 1944 and remained at 262 in 1945, suggesting that medical and nutritional interventions had at least partially contained the effects of deteriorating wartime conditions.Footnote 78
Estimated mortality rate among Jewish refugees in Shanghai, 1939–1946
Table 2. Long description
The table consists of nine columns and four rows.
Row 1 (Header): Year number. The columns are 1939, 1940, 1941, 1942, 1943, 1944, 1945, and 1946.
Row 2: Number of Deaths.
- 1939: 131
- 1940: 126 to 139
- 1941: 167 to 185
- 1942: 312 to 350
- 1943: 305 to 311
- 1944: 231 to 260
- 1945: 248 to 262
- 1946: 145
Row 3: Estimated number of Jewish refugees in Shanghai.
- 1939: 13,200 to 14,200
- 1940: 15,100 to 16,200
- 1941 to 1945: 17,000 to 18,000
- 1946: 14,600
Row 4: Estimated mortality rate.
- 1939: 0.92 percent to 0.99 percent
- 1940: 0.78 percent to 0.92 percent
- 1941: 0.93 percent to 1.09 percent
- 1942: 1.73 percent to 2.06 percent
- 1943: 1.69 percent to 1.83 percent
- 1944: 1.28 percent to 1.53 percent
- 1945: 1.38 percent to 1.54 percent
- 1946: 0.99 percent
In the years between 1941 and 1945, the JDC mobilised local resources and the professional expertise within the refugee community to sustain relief under extraordinary conditions of scarcity, surveillance and confinement. Shanghai’s Jewish physicians did more than provide emergency care. They sustained a fragile health system through improvised treatments, emergency organisation, and advocacy for nutritional and public health reform. It was in these darkest years that refugee physicians emerged not merely as beneficiaries of humanitarian governance, but as its primary architects.
Medicine in exile, knowledge in motion
The Jewish refugees in Shanghai represented a rare concentration of European physicians in wartime Asia, among whom were graduates of some of Europe’s most prestigious medical institutions. Yet in Shanghai they confronted a radically different environment: diseases with which they had limited experience, wartime shortages of familiar medicines and facilities, and a local population whose medical practices and beliefs differed sharply from their own. Under these circumstances, refugee physicians emerged not only as healthcare providers and community leaders, but also as learners who adapted their biomedical training to new conditions and engaged seriously with Chinese medicine. In doing so, they reexamined core assumptions of their professional formation and became integral to Shanghai’s pluralistic, if fragile, wartime public health system.
Among these physicians, Dr. Theodor Friedrichs stands out for leaving one of the most detailed personal accounts of medical practice in exile. His memoir traces the transformation of his clinical routines as well as his growing engagement with Chinese medicine, its practitioners, and its underlying philosophies. It also offers a vivid portrait of the hybrid medical landscape of modern China, where Western biomedicine had secured a foothold in urban centres, but ordinary people still relied on traditional Chinese medicine for its accessibility and perceived effectiveness in treating local ailments.
Friedrichs’ encounter with Chinese patients drew him gradually into their medical culture. When he first opened his private practice, patients sought him out almost exclusively for Western interventions, particularly injections of Neosalvarsan, which Shanghai residents believed capable of curing everything from syphilis to flat feet.Footnote 82 Over time, however, clinical success and referrals from Chinese doctors expanded his clientele. He recorded with pride, for example, how he successfully treated a woman with a severely swollen abdomen using thirty grams of castor oil and cured her within twenty-four hours.Footnote 83
His attitude towards Chinese medical practitioners underwent a parallel evolution. Initially dismissive of Chinese medicine as unscientific, Friedrichs came to recognise the empirical skill of many Chinese physicians through sustained interaction. Among them was Dr. Zee, a cautious and versatile practitioner who inspired Friedrichs on multiple occasions. Friedrichs observed that while Chinese medical education appeared less theoretical and more apprenticeship-based than its European counterpart, its practitioners often possessed remarkable practical knowledge acquired through extensive clinical experience and sustained by distinctive traditions of professional training, ethics, and reputation.
The most significant change in Friedrichs’ outlook came through pharmacology. Like many Western-trained physicians, he had long acknowledged the usefulness of Chinese materia medica while rejecting its theoretical foundations. After two years of practising in Shanghai, especially amid a shortage of Western medicine, Friedrichs concluded that European medicine had limits and that many Chinese remedies, though difficult to explain biomedically, demonstrated clear clinical effectiveness. He began systematically documenting treatments that Western physicians had often ridiculed but that clinical experiences repeatedly validated.
The most consequential episode in Friedrichs’ engagement with Chinese medicine concerned Ku San Tze (苦参子, Brucea javanica). Following the outbreak of the Pacific War, imported pharmaceuticals became either unavailable or prohibitively expensive, leaving the refugee community vulnerable to amoebic dysentery, which at the time could be effectively treated only with emetine. The extreme shortage of emetine forced the community to seek alternatives. Dr. Zee recommended Ku San Tze, a type of Chinese nut, to be taken three times a day for ten days. The remedy proved remarkably effective. Administered with careful dosage and clinical vigilance, it helped the entire refugee community avert what might otherwise have become a devastating epidemic.
The episode also exposed the limitations of pharmaceutical standardisation. Several refugee doctors, recognising an opportunity for profit, processed Ku San Tze into tablet form by grinding the nuts and removing the oil, which they assumed to be therapeutically inert. Patients who took these tablets soon reported severe abdominal pain. The discarded oil, long preserved in Chinese practice through the consumption of crude nuts, appeared to play an important role in protecting the intestinal mucosa. The community ultimately returned to traditional preparation methods. For Friedrichs, this experience was an epiphany, for it demonstrated how biomedical precision could sometimes obscure forms of empirical knowledge refined over generations. By the end of the war, Friedrichs had not only expanded his engagement with Chinese materia medica but also turned to classical Chinese philosophy in an effort to understand the intellectual foundations of Chinese healing traditions. Decades later, Friedrichs recalled that former patients continued to thank him for ‘those Chinese nuts’ that had saved their lives.Footnote 84
The collaborative spirit that shaped these individual encounters found more formal institutional expression. The Hongkew Physicians’ Association, established in 1939 with Dr. Friedrichs as its first chair, launched its own journal, the Shanghai Medical Monthly, which became the official organ of the CAEJR’s Medical Board.Footnote 85 Initially published in German, the journal soon evolved into a trilingual platform featuring contributions from both European and Chinese physicians. From its inception, the Monthly aimed to promote not only scientific inquiry but also intercultural exchange, serving as a forum for professional collaboration and shared values across cultural divides.
The journal’s editorial vision, shaped by physicians working within refugee welfare organisations, explicitly rejected the notion that Shanghai was merely a temporary waystation. Instead, it called on doctors to engage seriously with ‘the peculiar characteristics of this country, its particular diseases and microbes’. Its editors acknowledged the scholarly value of traditional Chinese medicine at a time when most Western-trained physicians remained dismissive, urging refugee doctors to engage actively with Chinese counterparts whom they described not only as ‘representatives of an old culture of high standard’, but as practitioners who were ‘becoming leaders in medical science’. Behind such affirmations lay a broader intellectual disposition. As Dr. Frederick Reiss articulated it, tradition was ‘one of the cornerstones of upright thinking and upright action’, and medicine at its best was a profession dedicated to ‘the common good for benefit and progress of mankind as a whole’. In this spirit, the Shanghai Medical Monthly functioned not only as a platform for professional exchange but as an expression of the ethical humanism that animated refugee medical work.Footnote 86
The Monthly became a critical space for documenting clinical observations, particularly of subtropical diseases unfamiliar to most European-trained physicians. One of its main academic contributions lay in its timely and systematic reporting of new medical realities refugee physicians encountered in Shanghai. The articles covered conditions ranging from infectious diseases to reproductive disorders. Notably, many illnesses appeared to stem either from the city’s subtropical climate, such as dermatophytosis of the hands and feet, or from the psychosomatic stress of displacement, such as pruritus, male impotence, and anxiety. Among these, the community showed particular concern for infectious diseases and reproductive disorders, which dominated journal articles and public lectures organised for refugee physicians and welfare workers.Footnote 87
In treating these conditions, refugee doctors accumulated local medical knowledge through direct immersion in the city’s epidemiological environment. Some conditions, such as pruritus and dysentery, were not entirely unfamiliar, but were exacerbated by Shanghai’s hard and often contaminated water, carbolic soap and pervasive fly infestations. Others, such as dermatophytosis, opened new avenues for cross-cultural learning. Dr. Frederick Reiss published a detailed study tracing both the pathological and etymological dimensions of athlete’s foot. Drawing on the Ming dynasty physician Chen Shi Kung’s description of its development and aetiology, Reiss explained local terms for the condition (e.g., Tsu Kuo, Lan Chiao Ya, Hsiu tien lo), and endorsed the traditional remedy of dried tree cricket shells soaked in Cantonese vinegar.Footnote 88 While this cure might seem suspect to Western readers, Reiss supported his claim with data from the Chinese Red Cross Hospital, Peking Union Medical College, and his own survey of students at the Shanghai American School, which revealed a striking 68% infection rate.Footnote 89
Refugee physicians also extended their clinical reach beyond the refugee community to Chinese patients. Dr. Alfred W. Kneucker, for example, noted that Chinese patients frequently consulted general practitioners about fertility concerns. Over time, he came to recognise the profound personal and social significance of infertility in Chinese society, describing it as ‘one of the most serious issues of a man’s life’. In response, Kneucker published a series of articles on the complex syndrome of impotentia generandi, providing diagnostic guidelines for general practitioners and criteria for specialist referral.Footnote 90 These serialised publications illustrated both the sustained interaction between refugee physicians and local patients and the cultural sensitivity that shaped their practice.
Perhaps the most important expansion of refugee physicians’ medical knowledge came in the field of tropical and subtropical medicine. In Shanghai, they encountered illnesses that they had rarely if ever seen in Europe, and even familiar conditions often presented in clinically unfamiliar ways. As Dr. C. E. Mosse observed, subtropical diseases frequently defied the clinical expectations of European-trained clinicians.Footnote 91 Exsiccoses, for instance, appeared more suddenly and with greater severity than in temperate climates, and affected patients well beyond infancy. Without established research on the impact of Shanghai’s climate on the human body, refugee physicians worked from clinical observations alone. They were not only adapting to an alien environment but also actively expanding the scope of Western medicine within a new climatic and cultural context.
The diagnosis of dengue fever illustrates this dynamic with particular clarity. Before 1940, Western-trained physicians in China had largely denied the possibility of dengue transmission in Shanghai, on the grounds that the species known to carry the virus had not been detected in the region. From September 1940 onward, however, the Isolation Hospital began diagnosing dengue fever in a growing number of patients initially admitted with symptoms attributed to scarlet fever, measles, or typhus. After systematic observation and careful re-evaluation, physicians at the hospital confirmed dengue fever and challenged the prevailing single-vector theory of transmission. The failure to detect that carrier mosquito, they argued, did not preclude the disease. Instead, it was highly plausible that other species identified in the area, including Culex fatigans, Aedes aegypti, Aedes albopictus, and Aedes taeniorhynchus, or perhaps another previously unidentified species, were responsible for dengue transmission in Shanghai.Footnote 92
Building on this breakthrough, Jewish doctors collaborated closely with local institutions such as the Henry Lester Institute and Hospital, whose regular monthly reports provided further clinical evidence and confirmation. Founded in 1927 with the bequeathed fortune of British architect Henry Lester, the Institute was dedicated specifically to research in medicine, especially tropical medicine and parasitology. It was mandated to ‘be open to all nationalities, but especially Chinese’.Footnote 93 Together, the Isolation Hospital and Lester Institute assembled records documenting the progression of dengue fever from early signs such as bradycardia and headache to tongue discoloration and leukopenia in later stages. Strikingly, while the existing literature suggested that white blood cell counts could drop below 1,200, Shanghai physicians consistently observed counts no lower than 2,500. The doctors documented and published four representative cases showing variation by age, sex, and race, which made an important contribution to global dengue literature. Collaborative institutional access also generated comparative insights in other areas. Dr. Kneucker, for instance, reported that prostate cancer appeared markedly rare among Chinese patients, citing only four cases diagnosed at Lester Chinese Hospital over six years, a much lower rate than in Europe.Footnote 94 Although Dr. Kneucker offered no definitive explanation, he made the comparison based on data collected through the existing network of medical institutions in Shanghai, which provided a body of clinical data far larger than any individual practitioner could assemble independently.
Institutional access also provided crucial training opportunities for younger refugee physicians. As retrospective accounts noted, ‘many of the younger men, who had just completed their studies, were able to volunteer in hospitals and thus received ample opportunity to become acquainted with local and tropical diseases’. Placements at facilities including the Lester Institute and the two St. Luke’s Hospitals enabled emerging physicians to encounter disease presentations rarely seen in Europe.Footnote 95 In this way, wartime Shanghai became not merely a site of refugee survival but a frontier of clinical education and intercultural medical practice.
Conclusion
With the end of the war, refugee medicine gradually shifted from emergency relief towards repatriation and resettlement. Medical conditions improved with support from relief organisations such as the United Nations Relief and Rehabilitation Administration (UNRRA), and by 1946, mortality from diseases such as typhoid and dysentery had declined with the arrival of UNRRA food and medicine. Yet not all wartime wounds proved equally treatable. As nutritional crises and epidemic threats receded, mental health emerged as a major concern. One physician observed that only ‘a new–or the old–settled way of life’ could restore refugees’ calmness and peace of mind. This lingering sense of dislocation helps explain why most survivors left Shanghai as soon as conditions permitted. The Shanghai Refugee Hospital thus increasingly focused on the medical clearance and inoculation required for repatriation.Footnote 96 Although the refugee community rapidly dispersed after 1945, the medical institutions it created during wartime left durable legacies. The Shanghai Refugee Hospital survived the refugee era and became part of Shanghai’s postwar medical landscape.
The history of Jewish refugee medicine in wartime Shanghai demonstrates how a public health system could emerge under conditions of displacement, fragmented sovereignty, and political uncertainty. What began in 1938 as an emergency response to overcrowding, malnutrition, and epidemic disease gradually developed into an improvised yet integrated infrastructure of care, linking refugee organisations, municipal authorities, transnational philanthropy, and local medical institutions. Its reach extended beyond refugee survival, addressing longstanding deficiencies in affordable healthcare for lower-income foreign residents and making refugee health a site where the boundaries of ‘the public’ were negotiated across racial, jurisdictional, and political lines.
This system of humanitarian governance emerged amid profound institutional instability and material constraint. Municipal authority and local organisational support receded after the Japanese takeover of the city, transnational philanthropic support became intermittent, while the occupying authorities remained only marginally involved in refugee health. Yet these constraints also created space for displaced professionals to assume responsibilities that might otherwise have belonged to municipal or humanitarian authorities. Refugees thus became not merely recipients of care but increasingly its providers and administrators.
Refugee physicians were central to this transformation, and their significance extended beyond the administration of care. As clinicians and mediators across medical cultures, they also turned displacement into a distinctive context for medical knowledge production. Their wartime experience reveals a model of knowledge production shaped not primarily by laboratories or imperial research institutions, but by scarcity and sustained engagement with unfamiliar disease environments and medical traditions. Investigations into dengue fever, collaborations with local institutions, and the Ku San Tze episode suggest that localised empirical knowledge could not only complement standardised biomedicine but, at times, offer solutions unavailable within it. Exile, in this sense, did not simply disrupt medical careers or displace existing knowledge. It created conditions in which medical practice itself was reworked. Medicine in wartime Shanghai was not merely practised in exile; it was transformed by it.
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